Therapy Sign-up page – mwallistherapy.com

If we have spoken, or received an sms, and have arranged a session time, then I will have asked you to compete the sign-up form. The sign-up process formalises the reading of my terms and conditions for providing therapy. In the agreement below you agree to those terms and conditions. Please read the privacy policy here, and then complete the form below. Therapy sessions cannot begin without this acknowledgment being received. If you have questions, nows the time to ask…click here.

Therapy Sign-up

Name

First

Last

Date of Birth

Name of emergency contact

Phone number for emergency contact

Your physical address (in case of emergency)

Personal Information Storage

I understand my personal informaiton will be stored until MichaelWallisTherapy ceases to operate or I specifically request deletion

Confidential Information Storage

I understand all other information about me is ONLY retained while I am actively engaged in therapy and will be deleted as soon as practical when I stop appointments.

Legal Representation

I understand Michael does not participate in legal matters unless directed by a court to do so.

Information Release

I understand Michael may use parts of my story that do not make me uniquely identifiable in his Blog (animaception)

Information Disclosure

I understand Michael will release information about me (personal and possibly confidential) if he is concerned for my safety or welfare or the safety or welfare of children

Crisis Services

I understand Michael is NOT available between appointment times and I know who to contact in a crisis or emergency.

If you are human, leave this field blank.