Please complete this sheet and return it to me.

Name:

Address:

Mobile number:

Landline:

Date of Birth:

Email address:

GP’s details:

Current medication/s and dose, if applicable:

If any of these details change, please inform me so that all your details are kept up to date

Client’s name:  ……………………………………        

This document sets out the basis of our agreement. It lets you know what you can expect from coming to Therapy and sets out what is expected of you.  The contact is drafted in line with the UKCP guidelines [further information can be obtained from UKCP directly at: www.psychotherapy.org.uk.]

Appointments

Your appointment will be at…….………………….. each…………..………………

The session will last for 50 minutes. If you're late or delayed it will not be possible to extend the session beyond the usual finishing time. The time is reserved for you as agreed and is not available to others.  If you are unable to attend you will be charged the full rate for the missed appointment.

If I am unable to attend you will not be charged and I will endeavour to give you as much notice as possible and/or try and rearrange the session for another time. We have agreed that the sessions will continue on an open-ended basis.  We will agree a finishing date between us as appropriate.

Venue

Sessions will take place at 32 Church Crescent London N10 3NE.  As there is no waiting area or reception please do not come early. 

Fees

Currently agreed fee for each session is £ ……..……..  payable weekly or monthly by agreement and payment can be made by cheque, cash, or bank transfer

I review my fees yearly.

Personal information

Please provide your personal address, details of your GPs name and address. Please let me know if this alters or if you change your GP. I will retain this information only as long as our work together continues after which time it will be deleted.

Confidentiality

The contract between us is confidential. I will not disclose any information to a third party other than in the event that in my opinion there is a threat to your own safety or to the safety of others, or if I am obliged to do so by law.  If I do need to disclose information for these purposes I would try to do this in discussion with you and with your prior consent.  My governing body the UKCP requires me to have appropriate supervision for all clients.   In accordance with the data protection Act 1998, any records of our sessions will be kept confidential and held in secure manner.

Complaints

I abide by the UKCP’s ethical framework and professional conduct procedures. If at any time a cause for complaint arises that cannot be resolved between us, you may have recourse to the UKCP Independent complaints procedure.

Signed

Client   …………………………………………..      Therapist  ………………………………………….