Sanibel - Opting in to our Service

	e: admin@sanibel.org.uk \| t: 020 8532 2370 \| f: 020 8532 2379
	Sanibel Psychological Therapies is a registered charity (number 1133652, England and Wales) and a company limited by guarantee (number 7037120, England and Wales). Registered office: Lily House, 11 The Shrubberies, George Lane, South Woodford, London E18 1BD

To access our service you will need your reference number, found on the right hand side of your
letter.

Please complete the form below. Fields marked * are mandatory.

When you have finished, click the Submit Form button and an email will be sent to you confirming your place on the waiting list.

We will then contact you by telephone to arrange an appointment so please make sure you have a private contact number submitted.

*First Name & Surname:
*Client ID (Number is on the right hand side of your letter):
*Private Email Address:
*Contact Number (mobile preferred):
If any of your address details are incorrect, please write changes below:
*Please identify ethnicity:	White British Asian or British Asian - Indian Asian or British Asian - Pakistani Asian or British Asian - Bangladeshi Black or Black British - Caribbean Black or Black British - African Turkish Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Asian or British Asian - Chinese White Irish Eastern European Other
Other (Please state):