Therapy SignUp Form – michael wallis therapy

This form must be complefed before I can speak to you (or your child) therapeutically. Completing this form does not mean you must attend sessions, it just allows me to begin a therapeutic process.

This sign-up process formalises the acknowledment 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.

Payment Acknowledgment

Standard ($120 per 45 minute session)

Concessional ($60 per 45 min session)

Home Visit ($15) in addition to above fee

If you are human, leave this field blank.