Registration Form

Registration Form For Clients

Please complete and return

Personal information
Name
Address for correspondence Address you will be at during the call
Mobile phone	Email
Date of birth	Occupation (optional)
GP Name
Surgery Address	Telephone
Medical conditions	Medication
Emergency contact person (name, phone number) PLEASE SIGN HERE TO INDICATE PERMISSION FOR MIRIAM GRACE / BLUE SKIES TO HOLD THIS INFORMATION FOR THE DURATION OF YOUR TIME WORKING WITH HER ONLY. WHEN YOU LEAVE THESE CONTACT DETAILS WILL BE DELETED.	GDPR COMPLIANT SIGNATURE ………………………………………….

All client data is confidential and kept secure and protected. Personal information asked for here is kept in a separate from any therapeutic material and is password protected for use by Blue Skies only. We will use this information for contacting you if necessary. 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, this information (only) would be accessible to the therapist’s clinical supervisor and/or emergency medical professionals.

blue skies

Psychotherapy with Miriam Grace

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