Therapy Agreement

Is the client an Adult or Child/ Young Person?*

Adult (over 18)

Child/ young person (under 18)

Is the client attending as an individual or part of a couple/ group?*

Individual

Couple/ Group

Are you completing this as the client or on their behalf?*

As the client

On behalf of the client

As the client, I agree to be contacted*

Directly

Via a parent/ guardian/ carer

Client Contact Details

As the client, I agree to be contacted by Phone*

Yes

As the client, I agree to be contacted by Text*

Yes

As the client, I agree to be contacted by Email.*

Yes

Phone*

Email*

Address*

Preferred contact method

Parent/ Guardian/ Carer Contact Details

Parent/ guardian/ carer name*

Parent/ guardian/ carer phone*

Parent/ guardian/ carer email*

Parent/ guardian/ carer address*

Parent/ guardian/ carer preferred contact method*

Session Funding

If selecting insurance, indicate one other option for fees which are not covered by the Insurance Company.

Self (the person signing below)

Insurance

Organisation

Other person

Agreed session fee*

I understand a fee of £20 is payable for changes, cancellations and missed appointments with less than 50 hours notice (click the following link for information on reduced fee if COVID-19 related: Current Practice Information)

Insurance Funded (tick to confirm)

(Pre-)authorisation No.

I understand I am liable for any fees not covered by the insurance policy, such as due to an Excess on the claim.

I understand I am liable for any fees for changed, cancelled or missed appointments as these are not covered by the Insurance Company.

I understand I will be invoiced directly for any fees not covered by the Insurance Company and further sessions may not be possible until payment has been received.

As the client (tick to confirm),

I give consent for my personal and sensitive data, including case notes, to be safely stored by my therapist for a period of 7 years after the end of counselling, and then destroyed. See also information sheet Your Data and Rights.

I understand that, except for those fees covered by an Insurance Company or other Organisation, I am liable for all fees and that if any fees are outstanding further sessions may not be possible until payment has been received.

As the client (under 18) (tick to confirm),

I give consent for my personal and sensitive data, including case notes, to be safely stored by my therapist for a period of 7 years after my 18th birthday, then destroyed. See also information sheet Your Data and Rights.

I am not attending individual counselling elsewhere.

Where other agencies are involved in my care, for example a paediatrician, psychologist or social worker, I give consent for the fact that the therapy is taking place and details on general progress to be shared if required.

As the client's parent/ carer (tick to confirm),

Name of young person/ child*

Relationship to young person/ child as signing on their behalf*

I give consent for my child's personal and sensitive data, including case notes, to be safely stored by their therapist for a period of 7 years after their 18th birthday, then destroyed. See also information sheet Your Data and Rights.

My child is not attending individual counselling elsewhere.

My child is not attending relationship/ family counselling elsewhere.

Where other agencies are involved in my child's care, for example a paediatrician, psychologist or social worker, I give consent for the fact that the therapy is taking place and details on general progress to be shared if required.

I understand it is my responsibility to share any information, for example that the therapy is taking place, with other relevant parties such as another or an estranged parent.

I have read and agree to the contents of the sheet Counselling Information.

I have read and agree to the contents of the sheet Counselling Information (Couple/ Relationship).

I am not attending couple/ relationship counselling elsewhere.

If I am attending individual counselling, I have informed my therapist that I am attending couple/ relationship counselling as well, and will bring anything discussed there that is related to this work back to these sessions. This enables the therapy to be joined up.

I give consent to the details provided on this form to be safely stored. For more detail see information sheet Your Data and Rights.

Name*

Signature*

Date*

Counselling, Therapy, Supervision, Training