registration form Name * First Name Last Name Age * Date of Birth * Gender Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Next of Kin * Full name, relationship, contact info Reason for wanting therapy? * Goals you want to achieve during therapy * Previous therapy history * Any mental health diagnoses or medications * Additional notes they’d like to share * Consent I understand that I am being referred for therapy services. I consent to this referral and give permission for relevant personal, medical, and psychological information to be shared between the referring party and the therapist or therapy service, strictly for the purpose of assessment, support, and treatment planning. I understand that my information will be handled confidentially and in accordance with data protection laws. I understand that I can withdraw my consent at any time by notifying the referring party or therapy provider in writing. Yes Signature * (Type name or sign below) Thank you!
