Registration Form For Clients
Please complete and return
Personal information
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Name
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Address for correspondence
Address you will be at during the call
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Mobile phone | |
Date of birth | Occupation (optional)
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GP Name | |
Surgery Address
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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.
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GDPR COMPLIANT SIGNATURE
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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.