Registration Form and policy agreement

Registration Form and Policy Agreement

All new clients will need to complete this form. Please contact us via telephone or email if you have any questions or queries.

Full Name

Date of birth

Gender

Male
Female
Other

Phone Number

E-mail

Address

GP Details

In case of an emergency please give the name & number of who we should contact

Parent / Guardian name if under the age of 18

Parent / Guardian Phone Number

Parent / Guardian E-mail

School / College (if applicable)

Have you previously attended therapy?

Yes
No

If yes please describe the type of therapy you received, when and for how long.

Please list any other professional currently involved

Referral details - Please describe how you feel we can support you or someone you care for.

Please outline how your sessions will be funded

Self-funding
Health Insurance Cover
Combination of Self-funding and Insurance Cover
Other

Health Insurance details - please provide your Policy 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.

Cancellation with 48 hours or more notice = no charge
Cancellation between 24-48 hours notice = 50% session fee
Cancellation with less than 24 hours notice = full fee
You can cancel your appointment by email.

Payment

Invoices will be sent via email or text at the end of each month. Payment should be made within 7 days by either cash or bank transfer. If you are paying with a Health Insurance cover your policy will need to be activated before any sessions can commence.

Please confirm that you agree to the above policies by checking the following boxes.

Confidentiality Agreement
Cancellation Agreement
Payment Agreement

Thank You.

Date Field