Client Registration & Agreement

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Your details

Dr Emma Clarke

Counselling Psychologist

Client registration and agreement

Your details

Title
Name
Pronoun preference
DOB
Address
Postcode
Phone number
Email address

Next of kin contact details

Name
Phone number

GP/Mental health support service:

Unless you have been referred to me by a doctor, or you have specifically asked me to communicate with your GP/mental health worker, I will not tell them that I am seeing you. However, it can be useful for me to have their details in case of emergencies.

GP name
Address
Contact number
Mental health team address
Contact number
Professionals involved in your care

Reserving and Booking appointments

Appointments will be booked via direct correspondence with myself either verbally, by text, phone, or email.

Once we agree to begin therapy, we will set a fixed time, day, and frequency for sessions. From that point on, all scheduled sessions will be reserved exclusively for you. I will not make your appointment slot available to other clients unless expressly discussed with you otherwise.

These reserved appointments will be considered ‘booked’ on a rolling weekly or fortnightly basis. Each session will be rebooked at the end of your appointment, securing the next session for you.

Fees & Cancellation Policy

• Initial Consultation: A 15-minute phone consultation is offered free of charge.
• Session Fee: Individual 50-minute therapy sessions are charged at £130. I will review my fees annually and reserve the right to increase them based on any reasonable increase in costs.
• Payment: Fees for each session should be paid by bank transfer or PayPal 48 hours prior to the scheduled session to secure your appointment. Appointments scheduled on a Monday or Tuesday must be paid for by 5pm on the preceding Friday.

If payment is not received 48 hours before your session, I reserve the right to cancel the appointment, and the appropriate cancellation fee will apply.

Missed Appointments:

If you do not attend your appointment, and no contact is made to cancel or rearrange at least 48 hours prior (and by 5pm on the preceding Friday for appointments on Mondays or Tuesdays), you will be charged the full session fee.

Cancellation by Me:

If I need to cancel an appointment, I will give you as much notice as possible. While I will strive to avoid cancellations, occasionally there may be instances of short notice cancellations. In these cases, you will not be charged, and any pre-paid fees will roll over to the next appointment. If no future sessions are booked or you choose to end therapy at that point, the pre-paid fee will be refunded.

I reserve the right to withdraw treatment at any time.

Contact Outside of Appointments

Contact outside of agreed session times will be limited to arranging or cancelling appointments. I will endeavour to respond to you within 2 working days of contact made. I will make you aware of holidays or periods where I will be unavailable.

Please note that I am not available for immediate responses and cannot act as a crisis or emergency contact. If you require crisis support, I recommend you contact one of the following services.

• NHS 111
• Local crisis support numbers
• The Samaritans: 116 123 (24/7)
• Refuge (National Domestic Abuse Helpline): 0808 2000 247 (open 24/7, live chat service available Mon-Fri, 3pm-10pm)
• 999 (for emergencies)
• A&E (for emergencies)

It is your responsibility to use these emergency contacts in cases of crisis or imminent risk.

Zero tolerance policy

I uphold a zero-tolerance approach to any form of harassment, abuse, threats, criminal behaviour, or actions that compromise my safety or wellbeing. Should such behaviour occur, I reserve the right to terminate the current session and cancel any future appointments with immediate effect.

Limits of therapy

Everyone responds to therapy in their own way, and as such, specific outcomes cannot be guaranteed.

Confidentiality and privacy

I understand that your privacy and confidentiality is paramount to you and that you care about how your personal data is used. I respect and value the privacy of all my clients and will only collect and use data in a way that is consistent with my moral and legal obligations and your rights under the law. Please read my ‘privacy and confidentiality statement’ which I have provided alongside this registration agreement, before signing below. You can also find further information on my website https://dremmaclarke.uk under ‘website privacy policy’.

Statement of agreement

Please sign the statement to confirm:

I have read and understood the privacy and confidentiality statement provided to me as an addendum to this document ☐

I have read, understood and agree to abide by the terms and conditions outlined in this document☐

Client signature:…………………………………………………….. Date:…………………………..