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Client Information Form

We request the details below in order to fulfil both our legal and ethical requirements.

Please complete all of the questions below before clicking on the Submit button. If the question does not apply to you, please type N/A.

 

We would like to reassure you that we adhere to all laws and procedures in accordance with the General Data. Protection Regulation (GDPR) and other applicable data and privacy legislation and will only ever use your personal information to provide you with therapy services.

Your contact information

Date of Birth
Day
Month
Year
We will generally communicate with you by email. However, please let us know your preferences for communication with VIVA and your therapist.

Emergency Contacts

GP Details

Your relevant medical information

Have you had counselling previously?
Yes
No

How did you find VIVA?

For the sole purpose of marketing our practice, we would like to understand how clients find our details, and we would be grateful, therefore, if you would kindly let us know how you found VIVA.
Google
Counselling Directory
Psychology Today
Friend or family recommendation
Instagram
Facebook
Poster in coffee shop
Poster in GP surgery
Other
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