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 realtion 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.

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.
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
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New Patient Registration Form