Registration Form

Please review the Policies & Procedures by clicking here and then complete this registration form prior to your first appointment under Charlotte Haylock Psychology. Please be aware that in submitting this form you are agreeing to the terms and conditions of accepting treatment.

Legal name

First Name

Last Name

Preferred name (if different)

Please feel free to include your preferred title and/or pronouns if you wish to, but there is no pressure to do so

Date of birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency contact (name and telephone)

Your emergency person would only be contacted in the event of a true emergency. Your confidentiality is fully maintained according to legal and ethical standards

GP details (practice name, address and telephone)

You GP will not be routinely contacted as a result of filling out this form but is kept on file in the event that it is required. Your confidentiality is maintained according to professional and ethical standards.

If paying with insurance, please provide your insurance policy number and authorisation code (if applicable)

If you are using private insurance to pay for these services, please indicate your provider.

If paying with insurance, please confirm how many sessions have been initially authorised (if applicable).

Consent to treatment

I have read and understood your policies and procedures and consent to treatment.

I have read and understood your GDPR policy.

Consent to contact

I am happy to be contacted via email

I am happy to be contacted via telephone

Cancellation & rescheduling policy

We operate a standard 48 hour cancellation/rescheduling policy. If you need to cancel or reschedule please do provide us with a minimum of 48 hours notice. Payment will be required for sessions that are cancelled, rescheduled or missed with less than 48 hours notice

I have read, understood and agree to your cancellation and rescheduling policy.

Payment policy

I understand and agree that I am responsible for paying for all services provided.

If I am paying with insurance, I understand that I'm responsible for making payment in the event that my insurance provider declines payment for any reason.

Transfer of data

Clinical session notes and letters pertaining to your treatment are currently stored under the Harrison Psychology Group. As a client continuing to access therapy under Charlotte Haylock Psychology, it is required to have your clinical data (including, but not limited to, clinical notes and letters) copied over into Charlotte Haylock Psychology storage files. this is for the purposes of ongoing clinical care. This will be stored in line with the Charlotte Haylock Psychology GDPR policy. Please note that your existing data will also remain with the Harrison Psychology Group.

I understand and agree that my clinical data currently held by the Harrison Psychology Group (including clinical notes and letters) will be copied over into Charlotte Haylock Psychology storage files for the purposes of my ongoing clinical care.