REFERRALS

Refer myself

Adults who live in Camden or Islington, or have their GP within these areas, can be seen at the MPC. Adults who live outside these areas need to pay for their assessment.

There is a fee of £640 for your assessment at the Centre. Therapy sessions cost £160 and the minimum recommended would be 5 hours. Please ask your GP whether they would be prepared to refer you to the MPC and agree to pay for your assessment, and therapy if required. The referral letter, or form, will need to state that they will pay for your assessment. 

Otherwise, you can refer yourself using the form if you wish to pay for your assessment privately. 

We are not able to accept your referral unless we have written agreement to fund your assessment, whether by your GP or by yourself.

    Name (required)

    Date of birth (required)

    Title (required)
    MrMrsMsMissDrOther

    If "other", please enter your preferred title here:

    What would you like to be called by staff at the Centre? (required)

    Ethnicity (required):

    NHS no. (required)

    Home address (required)

    Post code (required)

    Country (required)

    Best phone number to contact you on during the day (required)

    Email (required)

    Preferred language (required)

    Interpreter needed (required)
    YesNo

    G.P.'s name and address [including postcode] (required)

    G.P.'s telephone number (required)

    Emergency contact [the name and number of the person we would call in an emergency if you are at the Centre] (required)

    Do you see any other professionals for help with anything? (required)
    YesNo

    If yes, please write down the name of the professional who you see, where you go to see them, and what you see them for.

    Do you have any health or mobility issues that we should be aware of? (required)
    YesNo

    If yes, please write down what these are.

    Do you currently take any medication? (required)
    YesNo

    If yes, please write down what you take and what it is for.

    Do you experience any of the following? (tick any that apply)
    Low mood or depression: NowIn the pastNeverNot sure
    Anxiety unrelated to stammering: NowIn the pastNeverNot sure

    Reason for contacting the MPC:

    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.

    Please write down any preferred days or times (during office hours) for staff to contact you.

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