Client Intake & Permission To Share

Client Intake & Permission to Share

Your Information
Doctors Information
Emergency Contact
Fees
Permission to share

YOUR INFORMATION

First Name

Last Name

Date of Birth

Gender

Home Phone

Mobile Phone

Address of Residence

Address Line 1

Address Line 2

Town

County

Postcode

DOCTOR INFORMATION

Name of Doctor (GP)

Practice Name

Practice Phone Number

Practice Residence

Address Line 1

Address Line 2

Town

County

Postcode

I authorize the release of confidential information regarding my treatment by Dr. Sonarzu Gullu-McPhee, BSc, (Hons), MSc, MA, Psy.D., CPsyhol to my own General Practitioner (GP) for the purpose of coordinating care.

Consent

Signature of Client

Sign Here

Date

Signature of Parent

Sign Here

Date

EMERGENCY CONTACT

Name of emergency contact

Relationship to you

Phone number

Emergency Contact Address

Address Line 1

Address Line 2

Town

County

Postcode

FEES

Person responsible for fees

Insurance company

Fees agreed

Date of 1st appointment

Email confirmation sent

PERMISSION TO SHARE

Permission to share statement

I agree to Dr Sonarzu Gullu-McPhee (Chartered Clinical Psychologist) sharing relevant clinical information with the following people

My GP

My Psychiatrist:

My Social Worker:

A designated contact

I would like professionals to receive copies of any reports/letters relevant to my current assessment/treatment

State relationship to designated contact

State professionals to receive copies of any reports/letters relevant to my current assessment/treatment

Date

I consent to have this website store my submitted information so they can respond to my inquiry and agree to the Privacy Policy

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Client Intake & Permission To Share

YOUR INFORMATION

DOCTOR INFORMATION

EMERGENCY CONTACT

FEES

PERMISSION TO SHARE

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