1. I have been advised by the practitioner the scope of the therapies available and give my full consent to receiving therapy sessions from the practitioner. I understand that results vary from person to person, and the agreement by the practitioner to work on the issues or problems presented by me, using whatever model or models are appropriate to my situation, in no way implies or guarantees a ‘cure’ of the said issues or problems.

2. It has been explained to me by the practitioner and I understand that therapy is a collaborative process, and the degree of progress is dependent on my active participation and engagement in the process. I understand that there are no guarantees offered and that success depends on my active participation and motivation. I understand that I am paying for the practitioners' time and not for a guarantee of success.

3. I understand that the therapy provided by the practitioner is not a replacement for medical treatment, psychological or psychiatric services or the appropriate counselling. I also understand that the practitioner does not treat, prescribe for, or diagnose any medical or mental health condition.

4. I declare that, if advised prior to any session with the practitioner to seek medical approval, I have consulted with my General Practitioner and/or Hospital Consultant and gained the appropriate medical approval for working with the practitioner

5. The number of sessions are discussed and agreed at the start and I agree to pay for any session prior to it taking place. When requested.

6. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability, and that contact between sessions will be strictly limited to telephone, email or letter.

7. I have accurately and truthfully answered the questions asked of me and provided background information as requested by the practitioner

8. I understand that any mp3 download/CD/recording for any of the talking therapies are provided for me at the practitioners' discretion. I agree that any such mp3 download/CD/recording is for my personal use only and that it is not to be lent, copied or sold under any circumstances. I will not listen to recordings while driving or using any kind of machinery

9. Confidentiality is paramount and will be maintained in all but the most exceptional circumstances. I agree that these can include: legal action (criminal or civil court cases where a court order is made demanding disclosure, including coroners’ courts); child abuse; if I am an imminent danger to myself or others; and where there is good cause to believe that not to disclose would cause danger of serious harm to others. Most standards of confidentiality applied in professional contexts are based on the Common Law concept of confidentiality where the duty to keep confidence is measured against the concept of ‘greater good’. The sharing of anonymous case histories with supervisors and peer-support groups is not a breach of professional confidentiality. The sharing of open case histories with supervisors and any referring NHS medical practitioner is also not a breach. The sharing of information with practice partners is also not a breach.

PLEASE NOTE: The practitioner reserves your sessions for you and it is his policy to charge the full fee for cancellations received with less than 48 hours’ notice, or non-attendance. By signing below, you agree to this.

I agree to the terms stated above signed ………………………….………… Date …...……….…………………...….

(Consent of Parent/Guardian Where needed)...........................................................................................................

Please PRINT Full Name(s)…………………….…………..……………...……………………………………………

Please carefully read and note the following: