Julia Scott Counselling

Registration

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Which service are you registering for? * Required

Will we be working in-person or online?

In-person

Online

Mixture / Not sure

As far as you are aware, do you know anybody who is currently having / has recently had therapy with me? * Required

Yes

Contact details

Name * Required

Phone (mobile or landline) * Required

Please enter a contact number in case I need to contact you at short notice (mobile preferred)

Email Address * Required

Enter email

Address * Required

Please note you will not be contacted by post without your permission, except in the event of unpaid invoices.

How may I contact you? * Required

Select all applicable

Mobile (telephone)

Mobile (SMS)

Landline

Can I leave a message for you if necessary? * Required

Yes

Medical details

Date of Birth * Required

Please ensure you enter the correct year

GP Surgery * Required

Please enter your surgery name, address and phone number

Medical conditions

Please enter any medical conditions it would be helpful for me to be aware of

Medications

Please enter any medications you are taking (if none, please enter "none")

Emergency contact name * Required

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.

Emergency contact phone number * Required

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.

Consent * Required

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

Less Annoying CRM

Thank you for completing the registration form.

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