Client Agreement | Elaine Owen

First Name *

Last Name *

Address *

City/Town *

County *

Postal Code *

Phone Number (Home)

Phone Number (Work)

Mobile Number *

Email Address *

Please note here any restrictions on contact0 / 180

Fee Agreed (per session) *

Address to which invoice to be sent (if not to client personally)

City/Town

County

Postal Code

Commencement date of counselling *

Frequency of sessions *

0 / 180

Date of birth *

General Practitioner's Name, Address & Tel No *

0 / 180

Any current prescribed medications *

0 / 180

Relevant medical conditions or treatments *

0 / 180

Any other organisations or agencies currently involved *

0 / 180

Confidentiality, Records and Ethics

Ethics: This Counselling Service complies with the Ethical Framework of the British Association for Counselling and Psychotherapy (BACP), respecting you as a person and honouring your trust. For details of their policies and procedures, see www.bacp.co.uk.

Confidentiality Statement *

I offer confidential counselling to all clients. I will not share information about you with anyone outside my Practice unless I have reason to believe that either you or someone else is at serious risk of harm. I will discuss any proposed disclosure with you unless I believe that to do so could increase the level of risk to you or to someone else. Please read the attached GDPR Confidentiality statement.

I have read and understood the Confidentiality statement.

Data Protection Statement *

I consent to Elaine Owen using my personal and sensitive personal data in accordance with the General Data Protection Regulation May 2018 for the purposes of delivering counselling to me, and for quality assurance, and assessing the effectiveness of those services.

I have read and understood the Data Protection statement.

Referrals *

I confirm my permission for my therapist to refer and provide relevant information if necessary, to any appropriate persons, organisations or agencies if she believes that there is a serious cause for concern about the health or welfare of myself or others.