Client/Supervisee Details

Why Is This Information Required?

This information may be used as follows – please read carefully:

  1. I will invoice you at your address for missed sessions where less than 48 hours notice has been given.
  2. In the event that you need medical attention, I will give this sheet to the emergency services.
  3. Should anything arise while you are in therapy that gives me serious concern for your wellbeing, I will contact the appropriate service (e.g. GP, police, social services), and I will let you know that I will be doing so.
  4. I may be legally required to disclose this information in a court of law.

Contact Information

Medical Information

Next Of Kin

Your Consent