Registration Form

New Patient Registration Form
Full Name*

First NameLast NameInitials
Residential Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of Birth

MonthDayYear
Date
Occupation
Phone Number*

Country CodePhone Number
E-mail*
example@example.com
How did you find me?*
Other
Next of Kin (Person to Contact in Case of Emergency)*

Street Address

Full name

Relationship to youContact Number

Postal / Zip Code
GP Details*

Name of GP

Name of GP Surgery

Contact NumberState / Province

Postal / Zip Code
Method of Funding*
Health Insurance Membership Number, if applicable
Health Insurance Preauthorization Code, if applicable
How many sessions has your insurance company authorised?
Our full terms and conditions can be found here. By checking the boxes below, you acknowledge that you have read the terms and conditions, and agree to them whilst working with any of the Clinical or Counseling Psychologists at Dianne Everitt and Associates.

Please take particular note of the following in relation to fees and cancellation of sessions.

Cancellation Policy

If you cancel an appointment with less than 24 hours notice, we cannot use that appointment for someone else and you will be billed for the cost of the session.

If you fail to cancel the appointment and do not attend you will be billed for the cost of the session.

*Please note that your health insurance will not cover late cancellations or missed sessions. If you miss a session, or do not cancel 24 hours before the session, you will be sent an invoice for the full session at the end of the month, to be paid by BACS.

Settlement of Fees

You will be liable for the settlement of fees, which can be paid by bank transfer following the receipt of an invoice.

If you are using insurance to cover the cost of your sessions, please note that you need to obtain preauthorization before the first appointment, and there may be an excess for you to cover, depending on your policy.

Use of AI

Sometimes, we use AI to assist with note taking during therapy sessions. We use Heidi Health, an AI tool specifically designed for healthcare practitioners.

- All session notes and reports generated with Heid Health are stored securely in accordance with applicable privacy laws and regulations (e.g., HIPAA, GDPR).

- Data entered into the AI system is encrypted and access is restricted to authorized personnel.

- Heidi Health will use secure technology to record the session, and create a summary thereafter.

- Transcripts are deleted once notes have been generated, and we do not store any recordings after the session

- Audio of the session is never recorded or saved

- Heidi Health prioritises confidentiality. The contents of the session will NOT be used to train AI, and nobody will have access to any of the content

- Content will in no way be made public, or available to anyone other than your therapist. Content is not used for any model training.

The use of AI is optional. It helps our therapists with note taking, and report writing where needed. Please indicate below whether you consent to Heidi Health being used during your sessions.
Consent for Heidi Health*

I consent for Heidi Health to be used during my sessionsI do not consent for Heidi Health to be used during my sessions
Acceptance of terms and conditions*

I acknowledge that I have read the full terms and conditions, and agree to themI accept the cancellation policyI accept responsibility for the settlement of fees
Should be Empty:

New Patient Registration Form