Client Registration - Gareth Willett

Client Registration - Therapy

One to One Coachee Registration

Name *

First

Last

Date of Birth *

DD/MM/YYYY

Full Address *

Mobile *

Use '00**' for international codes (e.g. 0044 for UK)

Email *

Next of Kin *

First

Last

Next of Kin Contact Number *

For use in cases of emergency

GP Name

GP Surgery & Address

GP Contact Number

Current Medication

For mental health purposes, please give details of current medication use; names and dosages

RISK: Are you experiencing any of the following? *

Suicidal thoughts and/or plans
Self-harm thoughts and/or plans
Any form of harm or abuse from another person(s)
Thoughts, plans or actions of any form of harm or abuse towards another person(s)
Any other form of risk not mentioned
I am NOT at risk or pose no risk in any way

Please tick those which apply to you and if there is any risk please give further details below.

If it's an emergency or you're in need of immediate help then your first point of call is to contact your Local GP or Emergency Services, or alternatively call NHS Direct on 111 or Samaritans on 116 123.

Further Details (Risk)

Health Insurance Provider
Leave blank if none

Health Insurance Membership Number

Number of Sessions Confirmed

Further Details (Health Insurance)

Further Details
Any other information that you feel is relevant

Please tick all to confirm you have read and agree to the following documents, which can be opened up into a new window through the relevant links below: *
Client Contract
Terms & Conditions
Privacy Policy