Islamic Counselling Therapy Booking

Islamic Therapy Booking Form (Confidential)

We will contact you via telephone for an initial chat and to arrange a booking. The call may be from a WITHELD NUMBER. Please answer the phone as our therapists only have a limited time to make calls.

Mr / Mrs / Miss / Ms / Other - Please enter

First Name/s

Surname

Address 1

Address 2

Town/City

Postcode

Country

Email Address

What is your age?

Best telephone number to call you on

What is your current faith?

Please tell us a little about what issues you are facing. Please give as much detail as possible.

Please tell us if you have received any help before for this issue. This can be counselling, talking therapy or medication etc.

Please tell us a little about your domestic situation. Are you single, married, separated, divorced, living with family etc.

Please tell us how you heard about Destination Islam.

Google Search

Instagram

Tick Tock

Facebook

YouTube

Referred by Friend

Leaflet / Card through Door

Other*

*If Other please specify where. Thank You.