MPC development

MPC development

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Private adults self-referral

MM slash DD slash YYYY
Title(Required)
Interpreter needed(Required)
Do you see any other professionals for help with anything?(Required)
Do you have any health or mobility issues that we should be aware of?(Required)
Do you currently take any medication?(Required)

Do you experience any of the following? (tick any that apply)

I understand that there is a fee to be seen privately at the Michael Palin Centre at that appointments are made only when payment is received.(Required)

A member of the Michael Palin Centre staff will contact you by phone or by email about your self-referral and how to pay for a private assessment.

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    I’m also happy for the Michael Palin Centre to call me occasionally about supporting the Centre’s work.
    Charitable donations to the Michael Palin Centre are administered by The Whittington Health Charity, Registered Charity Number 1056452 www.whittingtonhealthcharity.org. For this purpose alone, The Whittington Health Charity will also hold your details. We take your privacy seriously and will never sell or swap your details with other third parties. You can withdraw your consent to be contacted at any time by calling 020 3316 8100 or by emailing [email protected] Information about how the Trust protects personal data is set out in our privacy policy.
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