Consent Form | Kate Devereux Therap

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To support you in preparing for our upcoming therapy session, I have sent you the Therapy Agreement for your review. When you feel ready, please complete the forms below. If you have any questions or need clarification about the agreement, please feel free to reach out.

I look forward to meeting with you and starting this journey together.

Kate Devereux Counselling & Psychotherapy

Client Demographics Form

Capturing client demographics helps me tailor my counselling services to better meet individual needs, ensuring that I provide the most relevant and effective support.

First name*

Last name*

Address*

How Did You Hear About Me?*

Age*

18 - 24yrs

25 - 34yrs

35 - 44yrs

45 - 54yrs

55 - 64yrs

65yrs & Over

Gender

Male

Female

Non-binary

Prefer not to say

Other

Marital Status

Ethnicity

White

Mixed or Multiple Ethnic Groups

Asian or Asian British

Black, Black British, Caribbean, or African

Other

Religious or Spiritual Affiliation

No Religion

Christian: Church of England, Roman Catholic, Protestant (e.g Methodist, Baptist), Orthodox (e.g Greek Orthodox, Russian Orthodox), Other Christian

Buddist

Hindu

Jewish

Muslim: Sunni, Shia, Other Muslim

Sikh

Pagan: Wiccan, Druid, Heathen, Other Pagan

Other

Employment Status

Kate Devereux Counselling & Psychotherapy

Therapy Agreement Consent Form

Please complete the form below to indicate that you have read and accept the Therapy Agreement.

First name*

Last name*

Phone*

Email*

Date*

Information Sharing

I confirm that I give my consent to liaise (share information about me) with the following people, if necessary, on a confidential basis.

GP Name*

GP Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship To You*

Contact Me

The Therapy Rooms, Hoyland House

Painswick, GL6 6RD

Mail: kate@katedevereux.co.uk

Tel: 07871 154539

Name*

Email*

Phone*

Message*

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