Please fill in the questionnaire to start your psychotherapeutic journey. Please note that all information provided in this questionnaire will be kept confidential. This journey will correspond to the laws of the UK where Phoenix Therapy is based.

Time since last physical examination:

Below is a table of common difficulties. Please tick the boxes that may apply and also add any that I may have missed.

If you smoke, or use tobacco what is the quantity that you smoke on:

If you've come here today wanting to quit smoking, what is your desire to quit smoking for the rest of your life on a scale of 1 to 10.

If you use alcohol what alcohol do you drink and how much do you consume?

If you use drugs, both recreational or prescribed, how much do you take?

Are there any additional needs that we should take into consideration for the duration of your treatment with us?

As part of the NationalHypnotherapy /Counselling Societyand the GHRPhoenix therapy is bound by the following code of ethics. For a full copy of the code of ethics that I adhere to please view them at:

http://www.nationalcounsellingsociety.org/about/codeofethics/

http://www.nationalhypnotherapysociety.org/about/code-of-ethics/

http://www.general-hypnotherapy-register.com/code-of-ethics/

When you agree to enter a contract withPhoenix therapy, you also agree to the following terms and conditions about how your data is stored and used.

All data is securely kept as per the recommendations and legislation set out by GDP, the ICO and data protection laws.If you wish to enquire about your rights you may do so with me in the first instance failing that you may contact the ICO directly. The data I shall collect will be via written questionnaires, your notes and tests such as a PHQ9 or GAD7, if applicable. The purpose of collectionis to assistin your treatment. Your data will be kept for approximately 7 years;this is for insurance and professional body reasons. After the sevenyear period, your data will be securely destroyed. All session notes will be secured in a locked filing cabinet for the duration of the sevenyear period. All data secured on an electronic device which would be insurance documentation, anonymous statistical data for charities, etc will be encrypted with a unique password both on the relevant document and on the company's cloud. Phoenix Therapy is not resposnisbility for breaches by other software providers such as Zoom.  Confidentiality may be breached if it is within the public interest to do so as mentioned in the aforementioned section. If confidentiality has to be breached legally, the client will not be informed of the breach for the safety of Phoenix therapy staff. If the client wishes us to release or share information, for example, to provide evidence for the benefits tribunal, thena written letter must be provided which is signed and dated with specific instructions as to which information is to be revealed and to whom. A copy of the data protection policy may be made available to you upon your request.ll matters regarding data protection will be referred to Brian Turner, who will be acting as the data controller for Phoenix therapy Ltd. In accordance with article sixoftheGDPR anddata protectionregulations the recording of any sessionwithout the explicit written consent of allparties is strictly prohibited All requests regarding requesting notes or editing notes that are erroneousmust be made in writing on a signed letter addressed to Brian Turner, Phoenix therapy, C/O Marie S19 King Street, Wakefield, WF1 2SQ. All requests will be dealt with within a 28 day period. If the client is under 18 an appropriate adult will be required to sign the therapy contract. Whether an adult remains in the room during therapy will depend on whether the client is considered Gillick competent

By signing this document, and checking the boxes on GDPR consent, I hereby acknowledge and fully understand the implications of the terms as stated above. Full policy can be found on my website at: https://www.phoenix-therapy.co.uk/policies

In requesting professional consultation and assistance, I understand that to be successful, I must be entirely willing to:

A) You agree to the use of some or all of the following treatments for therapeutic reasons at a the cost stated. The price will not increase, unless there is a break of more than three months between appointments.

B) You accept that the treatment is offered on the basis of the information you supply, and affirm that this has been complete and truthful.

C) You accept that an agreement to work on the issues presented does not imply that a particular outcome of therapy can be guaranteed and that fees charged are for the therapist’s time.

D) Non attendance: appointments can be rescheduled and cancelled 24 hours notice is required. If you fail to attend without notice you will be liable to pay the full cost of the session.

E) You are free to withdraw from therapy at any time. Any charges will be subject to item

F) If you arrive more than 5 minutes late you may have to shorten or reschedule your appointment.

G) Anti social behaviour will cause the immediate cessation of treatment.

H) The informationthatyou provide will be kept confidential unless one of the following applies:

There is a legal obligation to share the information e.g. when the Children’s Act applies or a warrant / court order is issued. You demonstrate you are a danger to yourselves or others If you say you have committed a crime, (such as financing or committing an act of terrorism, drug or human trafficking, money laundering) If you have committed these acts I am legally bound to break confidentiality and I will do so without informing you that this has occurred. If I am providing Counselling for you as a requirement of your formal hypnotherapy / counselling training at your College I retain the right at any time, with full transparency, to inform your College Tutor if I have reason to believe that you are presenting as not ready(fitness to practice) to be in any form of placement working with real clients.

I) If you have been referred by your GP or employer, or if I am working with you as part of a care team, I will share prearranged levels of information with appropriately agencies. I may use our work in a supervisory setting; this information will be kept confidential and you will remain anonyms throughout any communication with any clinical supervisor.

J) All jursitiction of online activity remains in the UK where Phoenix therpay is based. Phoenix threray does not take resposnibility for security breaches that occur with third party software such as Zoom, Google, Jotform etc. 

K) If you have any problems, questions or complaints about your therapy, you agree to talk with me about them first. If we can't resolve the situation then you have access to the formal complaints procedure of the following organisations displayed on my website: http://www.phoenixtherapy.co.uk/policies/

In order to support you in deriving maximum benefit from our scheduled time together, I agree to:

Use the best of my abilities and expertise to facilitate such changes as are mutually agreed to be in your interest and in no way harmful to you.

To ork diligently on your behalf to ensure the best possible outcome for you, the client

To abide by all code of ethics provided by my given regulatory body.

Offer you my undivided attention and professional assistance during our scheduled consultations.

Inform you immediately if, in my judgement, you would be better served by another professional or an alternative means of achieving your objectives.

I am professionally committed to assisting you in the shortest possible time and at the lowest possible cost in mobilising your resources to achieve maximum results.