Start Your Journey

New Client Referral Form

Welcome to ACPP

Are you a new client, or already working with us?

Step 1 of 5

About You

Fields marked * are required.

Full Name * Please enter your full name.

Age * Please enter a valid age.

Phone Number * Please enter your phone number.

Email Address * Please enter a valid email address.

Step 1 of 4

About You

Fields marked * are required.

Full Name * Please enter your full name.

Phone Number * Please enter your phone number.

Email Address * Please enter a valid email address.

Step 2 of 4

Session

Session type *

In-person

Online

Please select a session type.

Which branch would you like to visit? *

Maadi

District 5

Please select a branch.

Step 2 of 5

Your Needs

What brings you in? * Please tell us what brings you in.

Have you had therapy before? *

Yes

Please select an option.

Are you currently on psychiatric medication? *

Yes

Please select an option.

Please specify your current medications

Have you ever been given a diagnosis? (optional)

What are your goals for therapy? * Please describe your goals.

Step 3 of 5

Session Preferences

Session type *

In-person

Online

Please select a session type.

Which branch would you like to visit? *

Maadi

District 5

Please select a branch.

Note: Online sessions are priced higher than in-person sessions. Our team will confirm the exact fee when they contact you.

Country * Please enter your country.

Time Zone * Please select your time zone.

Preferred therapist gender

No preference

Female

Male

Preferred language *

Arabic

English

Either

Please select a language preference.

Step 4 of 5

Choose Your Therapist

Pick a specific therapist to book a session instantly, or let our team match you.

Please make a selection.

Available appointments in the next 2 weeks

Please select an appointment slot.

Preferred days (select all that apply)

Sunday

Monday

Tuesday

Wednesday

Thursday

Saturday

Preferred time of day

Morning

Afternoon

Evening

Step 4 of 4

Review & Confirm

Payment

Please send your session payment via InstaPay, then attach a screenshot of the payment below.

Click to Pay via InstaPay →

Send to acpp.gaia.paymentlink@instapay · Powered by InstaPay

Attach payment screenshot * Please attach a screenshot of your payment before submitting.

Something went wrong. Please try again or contact us directly.

Step 5 of 5

Final Details

How did you hear about us? *

Instagram

Facebook

Friend / Family

Google

Therapist referral

Other

Please let us know how you found us.

Anything else you'd like us to know? (optional)

Payment

Please send your session payment via InstaPay, then attach a screenshot of the payment below.

Click to Pay via InstaPay →

Send to acpp.gaia.paymentlink@instapay · Powered by InstaPay

Attach payment screenshot * Please attach a screenshot of your payment before submitting.

Something went wrong. Please try again or contact us directly.

✓

You're all set!

Thank you for reaching out. Our team will review your information and be in touch shortly to confirm your appointment.

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