This information will be kept securely and only used to contact you about your child’s therapy sessions.

Please indicate your preferences for communication about your child’s therapy sessions.

Sometimes, including the child in the communication is appropriate for older children / those nearing 18 yrs.

Please indicate your consent to proceed with therapy.

Please select your agreement to payments and fees

The following information would be only be used in a genuine urgent or emergency situation:

It is assumed that you would be the contact point in an urgent or emergency situation. If you would like anyone else contacted in such a situation, please include their details here. If not please leave blank:

Please provide here any other information you like Behypnotherapy to bear in mind in terms of this form