My Blog

Elementor #10

Client Name:

Address:

Marital Status: Length of Relationship:

Age Occupation: Email:

Telephone: Home Mobile

Preferred method of Contact:

In exceptional circumstances, I may need to contact your GP. This will be discussed with you prior to contact being made.

Do I have your consent to contact your GP? YES NO Name & Address of GP What is the main reason for seeking counselling?

Do you currently have any physical or mental health problems? YES NO

If yes, please state

Are you currently on any medication? YES NO

If yes, please state

Please note that fees payable will be discussed in advance. No charge is made for cancellations if 2 working days’ notice is given. A late cancellation charge of 100% of the payable fee may be made for cancellations of less than 2 working days’ notice.

Please sign to say that you have received a full copy of my terms and conditions of business.

Signed

(A typed signature is acceptable)

Date

I confirm that I have received a full copy of the terms and conditions.

► Necessary Cookies Always Active

Necessary cookies enable essential site features like secure log-ins and consent preference adjustments. They do not store personal data.

► Functional Cookies Remark

Functional cookies support features like content sharing on social media, collecting feedback, and enabling third-party tools.

► Analytical Cookies Remark

Analytical cookies track visitor interactions, providing insights on metrics like visitor count, bounce rate, and traffic sources.

► Advertisement Cookies Remark

Advertisement cookies deliver personalized ads based on your previous visits and analyze the effectiveness of ad campaigns.