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.

 

 


Comments

Registration Form — No Comments

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.

HTML tags allowed in your comment: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>