Mindspace Counselling Registration Form

Personal Details

Title

Are you over 18?

Gender

Please say how you identify:

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Age

Flat/House No. & Street Name

Town / City

Postcode

Please enter with NO spaces e.g. PH28EH

Mobile Phone

Home Phone

Preferred Phone

Can we leave a message on this number?

Reason for attending

Please specify:

Employment Status

Please specify:

Permission to Share Agreement

Due to our confidentiality policy we require your consent to contact a third party to book any appointments on your behalf, without your permission we are unable to do this. Are you happy to share information with (a) named individual(s)?

Permission to Share Agreement

Contact information for individual(s) you agree for us to share information with

Relationship

What information are you happy to share?

When would you like this agreement to end?

Please select a date for this agreement to end

Please say when you no longer wish us to share information with this contact.

Emergency Contact Details

Emergency Contact Details: Name

Emergency Contact Details: Tel No.

Additional Information

Do you have a disability or any special access requirements?

How did you hear about us?

Data Protection Statement

Your personal information will be processed and kept secure in accordance with Mindspace Limited Privacy Policy(Statement and the full policy are available on our website) and in line with GDPR (2018) regulations. This includes processing your data for registration and your anonymised collective data for reporting and funding purposes. We will not pass your information to third parties without your permission. However, if we are concerned about your safety or the safety of others, and where required by law, we will give your details to appropriate third parties.

Do you consent to us keeping your details for the purposes outlined above?

Yes

Date (DD/MM/YYYY)

In addition and separately from using personal information as described above, we would like to contact you from time to time with details of other courses or events we are running. Are you happy to receive this communication?

YesNo

If yes, how you would like us to communicate with you

Contact Information

Monday 9-1	Monday 1-4	Monday 4-7
Tuesday 9-1	Tuesday 1-4	Tuesday 4-7
Wednesday 9-1	Wednesday 1-4	Wednesday 4-7
Thursday 9-1	Thursday 1-4	Thursday 4-7
Friday 9-1	Friday 1-5	Saturday 9-1