Registration Form | Sandie Crowe

Please complete the Registration Form prior to your first scheduled session. The form is secure and all submissions are encrypted and password protected. If you would prefer to download a PDF to print out please click here.

Client Personal Details
Please complete the details below
Name
First Last
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Phone*
Date of Birth*
Month
Day
Year
Gender
- Male
- Female
May I contact you by phone?
- Yes
- No
May I contact you by email?
- Yes
- No
Please supply an email address
Enter Email Confirm Email
How did you hear about me?
GP Details
Name of GP
Surgery name
Surgery Address
Street Address City ZIP / Postal Code
Surgery Phone Number
Data Protection
To comply with the Data Protection Act 2018 I need you to be aware of how I use and protect your information. Your client records are kept filed in a locked cabinet, inaccessible to the public or, unauthorised persons. Any computerised records will be encrypted and password protected. All information will remain confidential unless there is a moral or, legal obligation to disclose. As a qualified counsellor it is a mandatory requirement by my professional body (BACP) to attend regular clinical supervision whereby I will present and discuss our work. Your identity will be protected during consultation. I will ensure that your information is kept to a minimum, is factual and up to date. Your client records will be securely destroyed 3 years after the end of the current counselling relationship.
CONSENT*
I agree to the Data Protection Policy
I confirm I have read the statements above and I give my permission for my personal information to be used, including my telephone number and e-mail, for the duration of my therapy.
TERMS & CONDITIONS*
I agree to the Terms & Conditions
I confirm I have read the Terms & Conditions
Please confirm you're human

Client Personal Details

GP Details

Data Protection