Registration Form

Registration  Form

 

Personal information  
Name 
Address 
Daytime phone  Evening phone
Mobile phone  Email (optional)
Date of birth (optional)  Occupation (optional)
GP Name 
Surgery  Telephone
Medical conditions  Medication
Emergency contact person(name, phone number)

 

 

All client notes and data are confidential. Process notes (about your therapy sessions) are kept separate from your personal information, and kept secure and protected. Personal information asked for here is kept in a separate locked cabinet and also on computer for use by Blue Skies only. We will use this information for contacting you if necessary and once therapy has ended should you request to be on our mailing list.  In an emergency e.g. a client is taken ill during a session or the therapist is unable  to  attend and unable to cancel the session, then this information (only) would be accessible to the therapist’s clinical supervisor and/or emergency medical professionals.

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