Personal Information Sheet

 Please complete this sheet and return it to me.

 Name:

 Address:

Mobile number:

Date of Birth:

Email address:

GP’s details:

Current medication/s and dose, if applicable:

If any of these details change, please inform me so that all your details are kept up to date

Therapy Agreement

Client’s name:  ……………………………………                

This document sets out the basis of our agreement. It lets you know what you can expect from coming to Therapy and sets out what is expected of you.  The agreement is drafted in line with BACP guidelines https://www.bacp.co.uk

Appointments

Your appointment will be at…….………………….. each…………..………………

The session will last for 50 minutes. If you're late, the session will still end at the usual time.   This time is reserved for you and is not available to others. 

If you need to cancel
Missed sessions are charged at the full rate. The exception is planned holidays, you can miss up to two sessions per rolling calendar year without charge, as long as provide at least a week’s notice.

If I need to cancel

If I need to cancel a session, you will not be charged.  I will give you as much notice as possible if I need to cancel a session.  If possible, I will try to arrange an alternative time for us to meet. 

Planned Breaks

I will give you at least a month’s notice of any planned breaks which will usually include two weeks over the Christmas period, and the first two weeks of September.  You will not be charged for these breaks.

Ending Our Work Together

You can choose to end therapy at any time.  I ask that you allow a period of time for ending our sessions together so that we can complete the work we have been doing as much as possible. Ending relationships can often be challenging, and planning a period of ending gives us time to explore this.   This is something we would discuss and mutually agree upon.

Venue

Sessions will take place at ……...   There’s no waiting area, so please arrive on time. 

Online Sessions

Online Sessions will take place via Zoom.  To ensure privacy, I will send you a new link before each session.  Please make sure you are in a confidential space before logging on.

Fees

The agreed fee for each session is £ ……..……..  This is payable in advance at the start of each calendar month.  I will send you an invoice with a link to make payment.  If you wish to pay by cash, please let me know.

I review my fees annually each April.  I will give you at least 4 weeks’ notice of any planned price increase.

Personal information

Please provide your personal address and your GP’s name and address by completing the enclosed Personal Information Form. Please let me know if either of these changes or if you change your GP. I will retain this information only for as long as our work together continues, after which it will be deleted.

Confidentiality

Our work is confidential. I will not share any information about our work with anyone else, unless I believe there is a risk to your safety or someone else's safety, or if I am legally obliged to.  Where possible, I will discuss this with you first and seek your consent before sharing anything.

As a member of the BACP (my professional body), I am required to receive regular supervision for all my clients. This means I may discuss aspects of our work in supervision, though always in a way that protects your confidentiality.

Any records kept from our sessions will be stored securely and kept confidential, in line with the 1998 Data Protection Act.

Complaints

I work in accordance with the BACP's Ethical Framework and Professional Conduct Procedure. If you ever have a complaint that we're unable to resolve together, you have the right to contact the BACP directly. 

My BACP membership number is 01054048.

Signed

Client   …………………………………………..      Therapist  ………………………………………….