Registration Form

Please review our Policies & Procedures by clicking on the link below and complete this registration form prior to your initial consultation. Please be aware that in consenting you are agreeing to our terms and conditions of accepting treatment.

Policies & Procedures / Data Protection

Name

First Name

Last Name

Date of Birth

Mobile Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If you are using private insurance to pay for these services, please indicate your provider.

If paying with insurance, please provide your insurance policy number and authorisation code (if applicable)

This enables us to invoice your insurer directly.

If paying with insurance, please tell us how many sessions have been initially authorised (if applicable).

This enables us to track your sessions as therapy progresses.

Emergency Contact (Name & Phone)

Please note that we fully maintain your confidentiality according to legal and ethical standards. Your emergency person would only be contacted in the event of a true emergency.

Consent to Treatment

I have read and understood your policies and procedures and consent to treatment.

I have read and understood your GDPR policy.

Cancellation & Rescheduling Policy

We operate a standard 48 hour cancellation/rescheduling policy. If you need to cancel or reschedule please do provide us with a minimum of 48 hours notice. Payment will be required for sessions that are cancelled, rescheduled or missed with less than 48 hours notice.

I have read, understood and agree to your cancellation and rescheduling policy.

I understand and agree to pay for my session if I cancel with less than 48 hours notice.

Payment Policy

I understand and agree that I am responsible for paying for all services provided.

If I am paying with insurance, I understand that I'm responsible for making payment in the event that my insurance provider declines payment for any reason.

Please give us a brief description as to why you're seeking therapy at this time?