Client Registration & Consent Form (For First-Time Clients)

Client Registration & Consent Form (For First-Time Clients)

Please read our Terms & Conditions before submitting this form. Please submit separate forms for each individual client attending the sessions.
Primary Client Details:
Full Name*

First NameLast Name
Age*
Date of Birth (To confirm Age)*

DayMonthYear
Full Name of Legal Guardian (For Clients aged 21 yrs old & below)*
Please indicate 'NA' if not applicable.
Contact Number*

Area CodePhone Number
E-mail*
example@example.com
Address (For Billing & Emergency Purposes)*

Street Address

Street Address Line 2

CityState / Province

Postal CodeCountry
Emergency Contact Person*
Full Name
Emergency Contact Number*

Area CodePhone Number
Brief Summary of Points I Wish to Discuss*
Please acknowledge all of the following in order to proceed*

I have read the Terms & Conditions sent to me and agree to them by submitting this form.I have submitted the request for an appointment slot.I have noted that a booking fee will be required to confirm each requested appointment slot.All my co-clients, if any, have agreed to participate in this counselling process with me.
Please verify that you are human*
Signature of Client*

Clear