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 * Are you staying at the above address during lockdown? 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 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
