Registration form and policy agreement

Please complete this form when you are asked to register.

Full Name

Date of Birth

E-mail

Phone Number

Your address

Your GP's name and address

In the case of an emergency please provide the name and telephone number of the person we should contact

Have you previously attended therapy?

yes
no

If yes, when was this and for how long? Was it helpful?

Paragraph

Please list any other professionals currently involved

Referral details - please describe how you feel we can support you or someone you care about currently

How will your sessions be funded?

self funded
health insurance cover
other

Health Insurance details - please provide your policy name, number and activation code

Confidentiality Agreement.

All of the information we discuss in sessions will be confidential unless we have reason to believe that you or another person is at risk. In most circumstances we will have a conversation about this and decide what to do next and who to contact. However in some circumstances we may need to alert other people to keep you and or others safe before discussing this with you first. Session notes will be safely stored in a locked cabinet in accordance with our Professional Body Code of Conduct.

Cancellation Policy

It is possible to cancel your appointment in advance without incurring a charge.
There is no charge for cancellation with 48 hours or more notice
Cancellation between 24-48 hours notice will incur a 50% session fee
Cancellation with less than 24 hours notice = full fee
You can cancel your appointment by email.

Payments:

Payments are requested to be made by bank transfer following each session.

Please confirm that you agree to the following policys by clicking the check boxes below

confidentiality agreement
cancellation policy
payment agreement

Today's date

Thank you