Wellbeing Clinic Registration Form

Thank you for taking the time to fill out this form. If you need support filling out this form, please contact reception@clementjames.org or give us a call on 020 7221 8810.

The information gathered will be used to register you with ClementJames, or update the information that we already hold for you. The second part of the form is for us to be able to measure if, over time, there are any changes in your wellbeing as a result of attending activities or receiving support at ClementJames. The results will be used solely for the purpose of reviewing and improving our services and demonstrating the impact of our work to funders.

Privacy Notice

At The ClementJames Centre, we’re committed to protecting and respecting your privacy.

Please see our privacy notice here, which details how we store your personal information, and tick here when you have read and agree to the terms laid out in it.

Who We Can Support

Please be aware that we can only support residents who live in or who are housed in either Kensington & Chelsea, Hammersmith & Fulham or Westminster.

Please select the borough you are a resident of housed in:

We also have criteria that clients need to meet to access support. At least one of the following means that you are able to access support at the Centre.

Please select any of the following that apply to you:

Receiving benefits

Have a household income of less than £25,000

Living in social housing (this includes council, temporary accommodation and housing associations)

Child/ward receiving free school meals

None of the above

Unfortunately, you do not fit the criteria which clients need to meet in order to access services at our Centre.

We apologise for any inconvenience caused. Please do not fill out the rest of this form as we will not be able to register you for the Wellbeing Clinic.

Your Details

Title

First Name

Last Name

Gender

Date of Birth (dd/mm/yyyy)

Self-described gender:

Ethnicity

Other or self-described ethnicity:

Email

Contact Number

House Number & Street Name

Post Code

How did you hear about The ClementJames Centre?

Please tick here if you would like to be subscribed to our mailing list to hear about upcoming workshops, programmes, events and opportunities at The ClementJames Centre.

Please tick here if you would like to be subscribed to our Acupuncture and Wellbeing Support mailing list to hear about upcoming wellbeing programmes and events at The ClementJames Centre.

There are times when photographs of activities are taken for publicity and marketing purposes. This is really helpful for us to be able to show what we are doing in the community. Please tick here if you agree for your image to be used in this way.

Your Emergency Contact's Details

In the event of an emergency, it is really helpful for us to have someone we can contact for you. This could be a partner, relative or friend, for example.

Emergency Contact Full Name

Emergency Contact Relationship

Emergency Contact Number

Your Medical Information

Do you have any of the following medical conditions?

Epilepsy

Pacemaker

Haemophilia

Psoriasis

Pregnancy

Primary substance condition

Please provide more details:

Please tick below to confirm that you agree to inform the practitioner of any change to the above and give consent to on-going treatment

Please tick here

Confidentiality Agreement and Consent

The Clinic sessions take place in a group environment so please be aware that we cannot guarantee confidentiality in this space. We would encourage you to share only what you feel comfortable sharing in a group space. If you do share confidential information with our Clinic Coordinator, please be aware that there may be times where this information may need to be shared:

Where there is a safeguarding concern involving a child under the age of 18
Where there is a safeguarding concern and you, or someone else, may be at risk of immediate harm
When advice is being sought from a senior member of staff within The ClementJames Centre (this may be via email, telephone or face to face communication)
In instances of potential complaint/complaints, client communication will be shared with a senior member of staff to ensure transparency, safety and adherence to duty of care for all parties

In the above cases, the Clinic Coordinator will attempt to speak to you first before breaking confidentiality. However, should there be a clear safeguarding issue that is covered by one or more of these exceptions, this may not always be possible. In some circumstances it may be necessary to signpost clients to additional/alternative support, either internally within ClementJames or to a specialist organisation. What you can expect from the Clinic and the Clinic Coordinator:

A relaxed and calm space to connect with your inner well of peace
Ear acupuncture for detoxification, stress relief and wellbeing
A respectful and calm manner from the Clinic Coordinator
Health, wellbeing and spiritual development knowledge from a Chinese Medicine, western physiological health sciences and Vedanta meditation perspective

What The Clinic Coordinator can expect from you:

Respect
Sharing only what you feel comfortable to share in a group setting
Patience - there may be a few people waiting for their ear acupuncture treatment before you
Regular attendance at sessions
To ensure continued funding for the Wellbeing Ear Acupuncture Clinic, we ask you to fill in the questionnaires about how you are feeling and if the Clinic is having a positive impact on your wellbeing. Your feedback is very important in keeping the clinic going so we really appreciate your time in completing these forms.

Confidentiality Agreement and Consent

Information

Your ClementJames Wellbeing Clinic Coordinator has a BSc in Traditional Chinese Medicine Acupuncture, with 22 years’ experience as a practitioner and health science lecturer in higher education. They also have an MSc in Coaching and Mentoring and 31 years’ experience as a coach, with coaching experience in diverse settings such as with UK Olympic lifting teams and university staff and students. The Clinic Coordinator is also a qualified meditation teacher and has followed a path of meditation since 2003. The Chinese Medical model sees disharmony (physical, mental or spiritual) as occurring because there has been a disturbance which has disrupted the normal flow of Qi (energy). It is understood in Chinese Medicine that for healing to occur, the entire person’s body and Shen (spirit) must be involved to restore a smooth flow of Qi. The teachings of mindfulness and Vedanta meditation state that your true nature is peace, and peace is available to you when the mind is quietened and you are in the present moment. The Wellbeing Clinic space is underpinned by these principles. The Wellbeing Clinic Coordinator, Ray Rose Raymond, is employed by The ClementJames Centre to offer ear acupuncture services on Tuesdays from 2.30 - 5.30pm. I understand that if I chose to access other services offered by Ray Rose Raymond outside of these hours, that these are offered in their capacity as an independent practitioner. Services offered outside of these hours are not the responsibility of The ClementJames Centre and any concerns about the quality of practice should be directed to the British Acupuncture Council, who can be contacted through their website here.

Please tick below to confirm that you have understood and consent to the information laid out in the Wellbeing Clinic Confidentiality Agreement

Please tick here

Submit Your Form

Please submit the form below.