Supervisee registration (online)

Supervisee Registration (online)

Contact details

First 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 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 *

How may I contact you? *

Mobile (telephone)

Mobile (SMS)

Landline

Select all applicable

Can I leave a message for you if necessary? *

Yes

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

Contact details

Emergency contact

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Contact details

Emergency contact

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