Therapy Registration Form

Registration Form

Register for Therapy with Shaura Hall
Welcome. This registration form is for clients, students and therapists who want to work with me. You can save your progress with this form and revisit the it when you are ready.

My standard rates for psychotherapy, supervision and Yoga Therapy are on a sliding scale from £100-120.

If my fees are not affordable to you at this time, you may be interested in working with a psychotherapy student who is on placement for their diploma in Integration Psychotherapy. You can apply for subsidised Psychotherapy on the page below.

https://thepcip.org/integration-psychotherapy-services/
Please select the kind of work you want to do with me*
Full Name*

First NameSurname
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*

Confirmation Emailexample@example.com
Phone Number*

Country CodePhone Number

Please provide the details of at least one emergency contact *

Rows	Full Name	Relationship	Contact Number
Emergency Contact

Health History
Please provide some details about your mental wellbeing*
Have you ever been diagnosed with a neurodevelopmental condition?*
Please also indicate current diagnoses
Use this box to share a about your past and present mental health, include any information about mental health or psychiatric conditions you may have been diagnosed with.*
Please also indicate current diagnoses
Please list all current medications including purpose and dosage.*
Please list all current medical conditions, including asthma, emphysema, anemia, etc. *
Please also indicate current diagnoses
Do you have any physical injuries? *
Please describe recent drug use

Please list any recreational drugs you regularly use, including alcohol, cannabis, etc. *
Please describe recent drug use
Starting Point
Can you share a bit about what brings you to therapy at this time?*
Do you regularly engage in any meditation or mindfulness practices?*
Please describe recent drug use
Can you share a little about any yoga or movement practices you engage with.*
Please describe recent drug use

YesNo
YesNo
What is your current caseload (clients per week) at this time?*
How frequently do you need supervision sessions?*
What is your therapeutic modality? How long have you practiced this approach?*

Policy Notice

In the event that Shaura is able to provide you with therapy or supervision, the following terms and conditions will apply. Please take the time to carefully review payment policy as well and terms below, as you will need to agree to these terms before proceeding.
Terms & Conditions

By signing and submitting this form, you are agreeing to the following terms and conditions:
- I understand that therapy with Shaura may involve physical movement, breathing and meditation. I represent that to the best of my knowledge and belief I am able to participate in these aforementioned activities; in the event that I become unsure of my ability to participate in these activities I understand that I am liable for speaking with a GP or a healthcare professional of my choice to receive further counsel on how I should proceed.
- I understand that I am responsible for disclosing any concerns I may have about specific movements, meditations, or breathing exercises during my sessions with Shaura. I also recognise that I am responsible for explicating my medical and psychiatric history in so far as it may impact upon my needs in therapy with Shaura. I understand that Shaura Hall is not a medical professional and in the unlikely event that I incur injury during or as a result of my activities in therapy with Shaura, I will not hold Shaura Hall liable and hereby accept full responsibility for myself at all times.
- I have read and understood all of the information provided in this document and agree to adhere to the payment and cancellation policy as well as the terms and conditions set forth on page 5 of this document. I also understand that by signing this contract, I am assuming full responsibility for any and all consequences of breaching the terms and conditions set forth here.
Payment Terms

Shaura's standard rates for psychotherapy and individual supervision are offered on a sliding scale of £100-120 per 50 minute session. Yoga therapy is available for the same amount per 60 minute session. This amount must be paid in full prior to your session or immediately thereafter. All cancellations must be given with 24-hour notice. If you are unable to cancel at least 24-hours prior to your session or do not turn up, you will still be liable for the full rate.

The following account information must be used to initiate payments via a bank transfer. You are responsible for using these resources to verify you have entered the correct account information entered prior to finalising a transfer. Please be aware that we may be unable to stop payments sent to the wrong bank account and you may still be liable.

Bank Transfer Details

Name: Shaura Hall (Business)

Account Number: 78685554

Sort Code: 608371

IBAN: GB48SRLG6083717868555
Certify & Submit
I, First Name* Last Name* , hereby confirm that the information I have disclosed in this document is accurate to the best of my knowledge and belief.

By signing below I am also agreeing that I have understood the information outlined in this document and agree to adhere to the above-listed terms and conditions.
Date*

MonthDayYear
Date
Should be Empty:

Registration Form

Health History

Starting Point

Policy Notice

Terms & Conditions

Payment Terms

Certify & Submit