New client form Name * First Name Last Name Email * Phone * (###) ### #### Address * How did you hear about me? Referral BACP Counselling Directory Psychology Today Google search Are you on any mental health medication * Doctors surgery * Emergency contact (name and number) * First Name Last Name Phone (###) ### #### I consent * I consent to this form being sent to Charlotte and in accordance with GDPR and insurance requirements my data will be stored securely and destroyed after 5 years Thank you!
