Client Consultation Form Personal information Name * First Name Last Name Date of Birth * MM DD YYYY Gender Pronouns Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Contact number * Preferred contact method * In the event I need to contact you before our first meeting or outside sessions please select how you would like to be contacted. Text Email Emergency Contact Please add the details of someone who can be contacted in the event of an emergency Name * First Name Last Name Relationship * Contact Number * GP Practice Please provide your GP Surgery details GP Practice * GP Practice Contact Number * How did you here about me? * Please select one Counselling Directory BACP website Word of mouth I found your website on Google Facebook Psychology Today Other If other or word of mouth please detail here. Signature * By typing your name below you acknowledge that the information shared is true and accurate to the best of your knowledge. Please tick if you agree with the following * I confirm I have read, understood and agree with the terms set out in the privacy policy. I understand that this information will be deleted should I choose not to continue working with the counsellor after our first meeting. I understand that the first meeting is a free and one-off no obligation meeting with the purpose of understanding if myself and the counsellor would like to continue working together. I confirm I have read and understood the client counsellor contract and agree to the terms set out in this. I agree to receive marketing emails, promotions, discounts, and valuable resources from Turning Page Therapy, with the option to unsubscribe at any time. (Optional) Thank you for submitting your client information form to Turning Page Therapy.
