Registration Which service are you registering for? Counselling / EMDR / Coaching / SSPSupervision Will we be working in-person or online? In-personOnlineNot sure / mixture Contact details Full name Email Mobile number Address line 1 Address line 2 Town Postcode Are you staying at this address currently? YesNo Please enter the address you are currently staying at Medical details Date of birth GP Surgery Do you have any medical conditions or disabilities? YesNo Please provide details: Please give details of any medications you are taking: Emergency Contact Name Mobile number