Client Consent Form

Please complete the form below to provide the following information:

  • Your personal details
  • Your consent for me to contact your G.P. or other professional(s)
  • Your consent to the keeping of notes
  • Your agreement to my having clinical supervision for my work
  • Your receipt of the counselling contract

COVID-19

Please also complete the following pre-assessment COVID-19 screening questionnaire & liability waiver if you are seeing me in person.

You will find the main symptoms of COVID-19 listed by the NHS. If you indicate that you have any of these symptoms, are waiting for a test result or have tested positive, your appointment will have to be deferred until it is safe to see you. If you currently have symptoms of COVID-19 but have not yet used the NHS 111 online coronavirus service, then this is advisable to do so.
If you have had COVID-19 but are now well and no longer need to self-isolate, it may be necessary to seek permission from your GP before you have a session.
If the answer is ‘yes’, it will be necessary to defer your appointment until it is safe to do so.
If the answer is ‘yes’ to either question, it will be necessary to defer your appointment until it is safe to do so.
You will find who is classed as clinically extremely vulnerable and requires shielding on the NHS website. Those who require shielding will have received a letter from the NHS explaining this. Pregnant women are only considered at risk if they have been identified as ‘clinically vulnerable’ as in the same categories as non-pregnancy.
Unlike people at high risk, those who are classed as clinically vulnerable will not have received a letter from the NHS. If you meet the definition of someone who is clinically vulnerable, professional judgement will be decided whether the benefit of a counselling session (or energy healing session) is likely to outweigh any potential risk. If treatment is appropriate, it may be necessary to seek permission from your GP.