Registration Registration Which service are you registering for? Counselling / EMDR / Coaching / SSP Supervision Will we be working in-person or online? In-person Online Mixture / not sureMixture / not sure Contact details First name * Last name * Phone (mobile or landline) * Please enter a contact number in case I need to contact you at short notice (mobile preferred) Email Address * Enter Email Confirm Email Address * Confirm Email Address line 1 * Please note you will not be contacted by post without your permission, except in the event of unpaid invoices. Address line 2 Town * Postcode * Are you staying at the above address currently? Yes No Please provide the address you are staying at * This is just in case you become ill in the session and I need to let somebody know where you are. How may I contact you? * Mobile (telephone) Mobile (SMS) Landline Email Select all applicable Can I leave a message for you if necessary? * Yes No Medical Date of birth * GP surgery * Do you have any medical conditions or disabilities * Yes No Please give details * Medication Please give details of any medication you are taking Emergency contact Please provide the name and number of a trusted person I can contact in the event of an emergency situation arising during a session. This could be a friend or a family member or your GP surgery. Name * Phone * This form submits your contact details to Julia Scott for accounting purposes and your GP details in case I need to contact them in an emergency. Please read my Privacy Policy to find out how I protect and manage your data. Consent I consent to Julia Scott receiving the above details for the purposes described above Marketing I am happy to receive occasional newsletters from Julia Scott If you are human, leave this field blank.
