IOCPS Client Intake Form

Name *

Email Address *

Phone Number

Age *

Are you... *

Nationality *

Country of Residence *

County of Residence *

Occupation

Next of Kin

Next of Kin Contact Number

Additional information / reason for seeking therapy

I am aware that all sessions are confidential, but that where it may occur that the therapist perceives that I may be at risk of harming myself or others, that confidentiality may be breached. *YesNo

I consent to my information being held by the IOCPS for the duration of my attendance of therapy, and that said information will be held by the IOCPS for a period of no longer than five years after my final counselling session with the IOCPS. *YesNo

I understand that my information will not be given to third parties and only used within a counselling context. *YesNo

I am aware that I am responsible for ensuring the protection of my data in relation to counselling through the use of anti virus and firewall software, and removing the content of instant chat sessions on the devices I use for online counselling sessions. *YesNo

I understand that no audio/visual recording of sessions is permitted. *YesNo

I agree to be contacted via email / telephone for service feedback on completion of counselling with the IOCPS * *YesNo

Please tell us how you would like your appointment to take place. *If you are booking an Instant Chat appointment, please select that from the list.

How did you hear about us?

I agree to be contacted via email with any blogs or information that might be relevant.YesNo

IOCPS New Client Intake Form