Medical History Form

Full Name*

First NameLast Name

Date of Birth

What is your gender?

Email Address*

Phone Number*

Area CodePhone Number

Profession

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Please tick any items which indicate a problem to you

If other please supply details

Please indicate if any of the following apply to you. If they do, please enter full details about your condition in the NOTES box below

Notes

Are you currently taking any medication?*

YesNo

Medication & Condition

GP Name & Address*

Street Address

Street Address Line 2

CityCounty

Post Code

I am the client. I agree the therapy proposed which has been explained to me by the therapist. I understand the effects of the therapy may differ for different clients and a cure cannot be guaranteed. All sessions are held in the strictest of confidence and our privacy policy can be found in full at www.emdrharleystreet.com

Impact on legal cases or compensation claims, If you are involved in any legal proceedings or compensation claims, such as workers' compensation or personal injury, please be aware that progress in therapy may impact your case. Successful therapy could be seen as a change in your condition, potentially affecting the outcome of your claim. We strongly recommend that you consult with a legal professional before proceeding with therapy if you are currently engaged in any legal or compensation proceedings.

It has also been explained to me that if I cancel my appointment with less than 24 hours notice then the full session fee will be payable. If I cancel less than 48 hours notice then 50% of the session fee will be payable.

Please enter your name below as confirmation that you have read and understood this, all therapies are undertaken by UK law.

Name

First NameLast Name

Date

Kam Harris