Client Intake Form

This form must be completed by all new clients before therapy commences

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About You

Your Name(Required)

First Last

Date of birth(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Email Address for appointment reminders

If you would like your appointment reminders to be sent to an email address that’s different to the above, please add details

Email Address Confirm Email Address

Your Address(Required)

Street Address City ZIP / Postal Code

Phone Number(Required)

Gender pronouns

GP Name and Surgery Address(Required)

Next of kin/Emergency Contact Person

Name(Required)

First Last

Relationship to you(Required)

Contact Phone(Required)

Insurance Details

If the Services are being covered by your private healthcare insurance (e.g. AXA, Aviva, BUPA, etc.) please provide details below.

Insurance Company

Policy Number

Authorisation Number/Code

Consent

Do you give consent in principle to recording of sessions for supervision purposes?(Required)

Yes

No session will be recorded without your explicit verbal consent on the day of any appointment

Date(Required)

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About You

Next of kin/Emergency Contact Person

Insurance Details

Consent

Emotion Speaks

Join my mailing list

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