New client registration

Please use this form to register your details as a new client.

This form will be stored securely and will not be shared with anyone other than Tamara Bathgate, Counsellor.

Your data will be stored in conjunction with my Privacy Policy.

Your name

Age

Gender and preferred pronoun

Email

Telephone number

(###)

###

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If I need to call you, is it ok to leave message?

Are there any additional requirements you want me to know about, such as disability or religion?

GP name and practice contact details

Emergency contact name, their relationship to you and telephone number