Personal Details

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Explore Therapy

Thank you for choosing Being in it Together

Please complete the form below prior to starting therapy. All information if held in accordance with GDPR and Being in it Together is registered with ICO. If you have any queries, please do not hesitate to get in touch with us – contact@beinginittogether.co.uk

Name

Date Of Birth

Telephone Number

Address Line 1

Address Line 2

Town/City

Postcode

Do you have any health conditions you would like us to know about?

If Yes To The Above, Please Provide Details

Emergency Contact Name and Relationship

Please give us details of someone to contact in case of an emergency during session

Details you Contact

Emergency Contact Telephone Number

Emergency Permission

In case of an emergency, are you happy for us to tell your emergency contact that we are your therapist?

Medical Prescriptions

Are you currently taking any prescribed medication?

If Yes To The Above, Please Provide Details

Research & Writing Consent

See more information in contract.

Contract Agreement

I have read and agree to the terms in the therapeutic contract.