Intake Form

Please give a mark out of 10 for Symptom intensity.

Terms and Conditions

Confidentiality

All of our interactions (conversations, email, etc.) will remain strictly confidential, meaning that I will not share any information provided by you with anyone without your express consent unless you have told me that you are a harm to yourself or someone else in which case I would contact your doctor.

NHS Test and Trace

Confidentiality may be broken for reasons of public interest in the area of public health and your contact information may be shared with NHS Test and Trace, if I or some one I’ve been in contact with has tested positive for Covid-19.

Availability

You may feel free to contact me outside of our scheduled sessions by phone or by email. In fact, I encourage you to stay in touch via email as this provides an easily accessible way for me to monitor your progress and to add extra insights during your journey. I will do my best to return all phone calls and emails within 24-hours of receiving them (except when out of town or on holidays).

Commitments and Integrity

If I make a promise to you, this promise will be kept – in the way promised and in the time frame promised. If, in exceptional circumstances only, I am unable to keep a commitment, I will notify you of this as soon as I know of the need for change. I will deal with you at the highest standards of integrity, honesty, professionalism, and respect. I will let you know if at any point in time I feel that my involvement is not likely to make a positive difference in your life and/or business. By the same token, I expect you to keep any promises or commitments made during our sessions, including homework

Non-Judgement

I am not here to judge “right” or “wrong”. My position as therapist is to help you get the life you want. As there may be times when you will share information that may make you vulnerable, I assure you that I will treat your choices and actions (past, present, or future) with respect.

Feedback

Give and ask for feedback as much as possible. Let me know when something is working for you, as well as when something is not. The earlier the better. If I ever do or say anything that upsets you or doesn’t feel right, please bring it to my attention so that we can resolve it as soon as possible. My objective is to have a relationship that is fully open, honest, real and trusting!

Cancellations

It is important for us to keep our appointments, for your benefit, as well as the benefit of my other clients. 24-hour notice is required to cancel an appointment; I reserve the right to charge the full fee for a session cancelled with less than 24-hours notice. If you are delayed for an appointment, please call me to let me know 07753124187.

I ……………………………………………………………………hereby give my permission for you to collect and process the above information, including any sensitive personal information as defined under the General Data Protection Act (GDPR), and as required by you, the therapist, for the pursuance of both my own and your legitimate interests. I have read, understood and I accept your Privacy Notice in respect of the handling of my recorded data