New patient registration form

First Name (for patient) *

Last Name *

Date of birth *

Telephone number *

Contact email address *

Address *

Street address *Street address line 2

City

State

Postcode *

Country

GP practice and email *

Consent to share information with your GP (As per our prescribing policy, we are unable to prescribe if we do not have consent to share with your GP). *Please be advised we cannot prescribe for you, without sharing your clinical appointment letters with your GP.

Emergency contact *Please provide the name and mobile number of your next of kin. We would only need to contact them if there was an emergency situation.

Gender

MaleFemaleNon-binaryPrefer to self-describe (please specify below)Prefer not to say

Please specify

Ethnicity

WhiteMixed / Multiple ethnic groupsAsian / Asian BritishBlack / African / Caribbean / Black BritishOther ethnic group (please specify below)Prefer not to say

Please specify

Religion/belief

BuddhistChristianHinduJewishMuslimSikhNo religionOther religion or belief (please specify below)Prefer not to say

Please specify

Do you consider yourself to have a disability?

Yes (please specify below)NoDon't know

Please specify

Do you require an interpreter?

Yes (please specify below)No

Please specify

Where did you hear about our service from? *

I consent to the collection, storage and processing of my personal and health information in accordance with UK GDPR and the Data Protection Act 2018 for the purpose of providing psychological services. *

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