Client Registration

I’m excited to be working with you. In order for me to maintain accurate records and ensure that I can contact you, please complete the following client registration form.

I value privacy and want to avoid capturing unnecessary information about my clients, so you will see that I need a minimum amount of information and all fields are required. If you have any questions, just send me a message.

Looking forward to our session!

Preferred Pronouns

First Name

Last Name

Mobile Number

Date of Birth

Home Address

Address 1

Address 2

City

Post/Zip Code

Country

Emergency Contact Details

It’s important that you provide emergency contact details. I will never contact this person unless there is an emergency.

Emergency Contact Name

Relationship To You

Emergency Contact Number

Medical Notes

Please provide medical notes, diagnoses or any medications that are relevant to our work together. It’s ok if you have nothing to add here, please indicate that with N/A.

GP Name

GP Address

Relevant Medical Notes

Anything Else

Please let me know if there is anything else that you would like to tell me.

Message