Mustard Therapy & Coaching Client Registration Form

Mustard Therapy Client Registration Form

Please complete the details on the form below. This will form the basis of therapy, so accuracy is important. You may feel some of the questions don't appear particularly relevant to your situation. However it is essential for me to gain a basic understanding of your life circumstances to aid effective support.
Personal Details
Full Name*

First NameLast Name
Known as (if different)*
Date of Birth DD/MM/YYYY*

DayMonthYear
Date
Home phone number*
Mobile phone number*
Email address*
example@example.com
Address*

Street Address

Street Address Line 2

Town/CityCounty

Postal / Zip Code
Relationship Status*

MarriedCohabitingSingleDivorcedWidowed
If applicable, please give details
Any children? List Names & Ages*
Referral and Support Details
How did you hear about me or our Practice? *
Why did you choose to use my services in particular?*
GP's Name*
GP's Address*
Next of Kin & relationship to you*
Next of Kin address & phone number*
Please note: We would only contact them in an emergency
Are you currently taking any medication?*
If yes, please give details on the medication you are taking
Other Professional Support?*
Any Other Relevant Treatment? *
Support from Family & Friends? *
Any other support? *
Reason for Referral
Have you sought assistance from a Psychotherapist, Hypnotherapist or Counsellor Before?*
If yes, please give details on who you saw and when
What do you see as the presenting difficulties/reasons for seeking therapy?*
What are your expectations of coming to therapy? What outcomes are you hoping for?*
Current Life Circumstances
Physical health at present?*
Do you have issues with sleeping?*
Other Relevant Information
Have you ever had alcohol/substance misuse difficulties?*
Any significant medical history? In particular have you had any history of epilepsy OR psychosis?*
Are there any other issues that you feel may be relevant to your therapy?*
Consent

Seeking your consent to treatment in therapy is a legal and insurance requirement
I give permission for S Mustard to contact my GP/care co-ordinator, if it is deemed appropriate during the course of my treatment. I understand that the reasons would be fully discussed with me prior to contact being made. I understand that in this event, only information relevant to my treatment would be discussed.*

Yes, I agree
I wish to receive treatment from S Mustard based upon the presenting issues agreed and any additional issues that arise from subsequent sessions. I also confirm that I have read and understand the terms within the 'Mustard Therapy & Coaching' practice information below.*

Yes, I agree
'Mustard Therapy & Coaching' Practice Information

Client Co-operation:
Your commitment to participate fully in the process throughout the course of treatment is fundamental for reaching a positive outcome. It is essential therefore that you discuss any doubts you may have about the therapeutic process at any time. Although, as the therapist, I am there to facilitate the process of change, it is your effort that causes actual change. On occasion you may be given short written or mental tasks to perform. These are designed to be an integral part of your treatment, so your participation is essential.

Cancellation Policy:
If you need to cancel an appointment, there will be no charge if at least 24 hours notice is given; except for Monday appointments when cancellations must be received before 1pm on the preceding Saturday. However the full session fee will be payable if the cancellation is within 24 hours of the allocated time (or after 1pm on Saturday for following Monday appointments).

Late Policy:
If less than 10 minutes late, the remainder of the session will be able to proceed. However if more than 10 minutes late the session may have to be rearranged with a cancellation fee payable.

Confidentiality and Disclosure Policy:
I am legally required to comply with the Data Protection Act which sets out how confidential information must be handled. All information received regarding clients will be treated in the strictest confidence. This includes information gained directly from you in sessions, or from any third party and referral reports. I do make brief notes about our sessions which are securely locked away. You, as my client, can request to see these at any time.
We will not retain your personal information longer than necessary. Our insurance requires this is kept for 7 years beyond treatment. We will not use your information for marketing. To read our full privacy policy you can find the link to the PDF on our ‘About Us’ page on www.mustardtherapy.co.uk.
During the course of your treatment, it may be helpful to gain additional information from other professionals involved in your care. This will only be sought following a full explanation of the reasons and after gaining your written consent. Legally, I can only give or receive information if I have this proof of consent. If, for whatever reason, you do not give consent, we will need to discuss the continuation of your treatment. Please Note: Merely having your GP details does not give me permission to contact them.
However in extreme circumstances, your consent would not be required where there may be a risk of serious harm to oneself or others. It is for this reason I ask you to provide your GP details before commencing therapy, for use in emergencies. If this matter were to arise, I would do my best to discuss this with you in advance. This action is highly unlikely to occur but essential if the if a client's needs require additional support outside of the therapy relationship.
Please note: The exceptions to exclusive confidentiality are:
1. Where a criminal offence may have been or may about to be committed or is the subject of an ongoing police investigation. In this case, I have a legal duty to disclose such information.
2. Where there is significant risk to self or others.
Where appropriate, information may be shared with the other therapist within Mustard Therapy and Coaching, however, they are bound by the same confidentiality policy.
Should be Empty:

Mustard Therapy Client Registration Form

Personal Details

Referral and Support Details

Reason for Referral

Current Life Circumstances

Other Relevant Information

Consent