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Therapy intake form

Road Trip

HGI Information for Clients

Clinics:  Online, Bath and Bradford on Avon

Mobile: 07976 731429

Email: curtincounsellor@gmail.com
 

Terms of business

Cost of therapy (for private clients): £85 per hour, £100 per  1¼ hour session payable at each session.

Please Note:
a) The session fee is subject to revision from time to time. Advance notice will be given of any increase.

b) Human Givens therapists aim to meet the needs of their clients in as few sessions as possible and do not charge in advance for a course of treatment.


Cancellation policy: 24 hours notice of cancellation is normally required, otherwise the session fee will be payable in full.


Your personal information will be kept in accordance with the Data Protection legislation on the basis that you have given your consent to information about you being held by the therapist, which means that they will:

  • use your contact details only to get in touch with you about matters relating to your therapy, such as appointments and to provide helpful information, where appropriate, unless you have given your explicit consent for the therapist to contact you for other purposes.

  • retain notes of your treatment for a period of 7 years, in accordance with professional requirements and will take steps to ensure the security of the record.

  • not share your personal information with other individuals or organisations, except where they have reason to believe you or others to be at risk, or where there is a legal duty to disclose it, or as otherwise specified, if applicable. (If the last clause is applicable, your therapist will explain it to you.)

  • provide you with free access to the information they hold about you, should you wish.


Please read my Privacy Policy here.
 

If you have concerns about the accuracy or management of your personal information, please tell your therapist. If you are not satisfied with their response, you can contact the Information Commissioner’s Office (https://ico.org.uk/concerns, Telephone 0303 123 1113) and/or the HGI (see below).
 

Outcome measures

Your therapist uses various measures in order to gauge your response to treatment. If you are happy to do so, you will be asked to fill out some brief questionnaires before and after therapy sessions. These questionnaires help the therapist understand your needs, your past and present strengths and how best to help.
 

Your personal details and the information from the questionnaires will be treated as strictly confidential and in accordance with the terms of the data protection legislation. With your permission, the anonymised data from the questionnaires will be transferred to a secure database to be used for service evaluation and research. Signing the ‘Confidentiality Agreement’ will be taken to represent your agreement for your anonymised data to be used for service evaluation and research. You can withdraw your consent to this at any time by contacting your therapist.
 

Comments

If you have any feedback about your experience of receiving Human Givens therapy, or suggestions for improvements, please visit the HGI’s online feedback page. Alternatively, you can write to the HGI (see below for address). Feedback helps us to improve our training of therapists, their continuing professional development and the governance of the Human Givens Institute.
 

Concerns

If you have any concerns about your experience of receiving Human Givens therapy please contact the Human Givens Institute:
 

Address: The HGI Membership Secretary, Human Givens Institute, Chalvington, East Sussex, BN27 3TD, UK
Telephone: 01323 811662
E-mail: complaints@humangivens.com
Website: https://www.hgi.org.uk

HGI Complaints Procedure: https://www.hgi.org.uk/therapist-register/raising-concerns

The Human Givens Institute’s Code of Ethics and Conduct can be viewed at:
https://www.hgi.org.uk/about-hgi/ethics-and-conduct

If you would like a paper copy of the Policy, please contact the Human Givens Institute.

Confidentiality Agreement

Statements of understanding (please tick boxes)

  • use my contact details only to get in touch with me about matters relating to my treatment, such as appointments and to provide helpful information, where appropriate.

  • not share my personal information with other individuals or organisations, except where they have reason to believe that I or others to be at risk of harm, or where there is a legal duty to disclose it, or as otherwise specified in this document.

  • retain a record of my treatment for a period of 7 years, in accordance with professional requirements and will take steps to ensure the accuracy and security of the record.

  • provide me with access to the information they hold about me, if I request it.

Online sessions

I give permission for the therapist to put my name and contact details into an online calendar programme which sends out appointment reminders.
Yes
No
I would like to be added to a newsletter mailing list for news from Floresco. I understand I can unsubscribe at any time.
Yes
No

Client details

Birthday
Day
Month
Year

Next of kin details

GP details

About you

Do you eat regular meals?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you sleep well?
Yes
No
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