Supervisee Registration (online)Contact detailsFirst name *Last name *Date of birth *Phone (mobile or landline) *Please enter a contact number in case I need to contact you at short notice (mobile preferred)Email Address *Enter EmailConfirm Email Address *Confirm EmailAddress 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 during lockdown? Yes NoPlease provide your lockdown address *How may I contact you? * Mobile (telephone) Mobile (SMS) Landline EmailSelect all applicableCan I leave a message for you if necessary? * Yes NoEmergency contactPlease 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.
