Therapy SignUp Form – michael wallis therapy

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 Form

Your Name

First Name

Last Name

Your Email

Your Mobile Number

Your physical address (in case of emergencies)

The Name of your emergency contact person

First Name

Last Name

The mobile number of your emergency contact person

NOT a Crisis Service

I understand Michael is NOT available between appointments and I know who to contact in an emergency or crisis.

Information Sharing

I understand Michael will share my personal and confidential information if he becomes concerned for my welfare or safety or if he becomes concerned for the welfare and safety of others, in particular children.

Legal Proceedings

I understand that Michael will not participate in legal matter including providing support letters or reports unless required to do so under law.

Information Release

I grant Michael permission to use parts of my story that do not make me uniquely identifiable in marketing, blogs or his book podcasts or other media.

Personal Information Storage

I understand my personal information (eg the information on this form) will be stored until michaelwallistherapy ceases business or is no longer required by law or you request it is deleted in writing (email)

Confidential Information Storage

I understand that my confidential information will be retain ONLY while I remain actively engaged in therapy and will be deleted as soon as practical if therapy ceases subject to the conditions above.

If you are human, leave this field blank.