Registration Form - Clerestory Counselling

First Name

Last Name

Phone Number

Email Address

Address

GP Surgery Address

Gender

Do you take any regular medication? If yes, please provide details below: YesNo

Medical Info

Are you currently supported by any adult mental health care services? YesNo

Reason for seeking counselling:

Additional Medical Information

Consent to hold information for purposes of delivering a service (we never share your information with any other third parties)

Consent to receive mental health and wellbeing content and news about Clerestory Counselling services

We take privacy very seriously and will never share your data with any third parties outside of Clerestory Counselling and our affiliates unless it is for safeguarding purposes, a medical emergency which means we need to contact the emergency services or because it is essential for delivering a service to you.

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Client Registration Form