Client Consent Form

You are required to fill this in before attending your first session

We will receive verification of your form and inform the relevant nurse or therapist they may proceed with therapy sessions

In filling out this form digitally, you are agreeing that your electronic signature is the legally binding equivalent of your handwritten signature.

We know forms are boring, but mental health is serious. It shouldn't take too long.

Safe Data Encryption

Our data in encryption uses AES-256—the strongest encryption standard commercially available.

Are you filling this form out for:

If you are filling out this form for a dependent under the age of 18, please provide your full name and relation to the client

If you are completing this form for a dependent under the age of 18 and have not yet filled in the UNDER 18 REGISTRATION QUESTIONNAIRE, please click here before continuing with this form.

Today's date

Day

Month

Year

Personal details of client (the person who will receive therapy)

First name

Last name

Date of birth of client

Day

Month

Year

Which country are you based in?

Please provide us with a contacts in your community. This can be a next of kin and your doctor, for example.

Name of contact.

Contact phone number including international dialing code.

We'll need a parent or guardian to answer a few questions to get started