Please would you complete the client registration form below. I appreciate it may feel intrusive for me to ask for these details before meeting you, but it is important I have this information so that I can ensure your safety and wellbeing in the unlikely event of an emergency situation arising during our sessions. Please be assured that this information will be kept with highest regard for your confidentiality and will only be kept for as long as it is needed.

Please email me at enquiries@counsellingwestonsupermare.co.uk if you have any questions or concerns.

Client Registration (online)

Contact details

First name *

Last name *

Phone (mobile or landline) *

Please enter a contact number in case I need to contact you at short notice (mobile preferred)

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Address line 1 *

Please note you will not be contacted by post without your permission, except in the event of unpaid invoices.

Address line 2

Town *

Postcode *

Are you staying at the above address currently?

Yes

No

Please provide your lockdown address *

How may I contact you? *

Mobile (telephone)

Mobile (SMS)

Landline

Email

Select all applicable

Can I leave a message for you if necessary? *

Yes

No

Medical

Date of birth *

GP surgery *

Medication

Please give details of any medication you are taking

Emergency contact

Please provide the name and number of a trusted person I can contact in the event of an emergency situation arising during a therapy session. This could be a friend or a family member or your GP surgery.

Name *

Phone *

This form submits your contact details to Julia Scott for accounting purposes and your GP details in case I need to contact them in an emergency. Please read my Privacy Policy to find out how I protect and manage your data.

Consent

I consent to Julia Scott receiving the above details for the purposes described above

If you are human, leave this field blank.