Print Friendly, PDF & Email


The purpose of this form is to share some important principles, which guide my therapeutic practice so that your decision to embark on therapy with me can be based on accurate, informed expectations. Please read this carefully and feel free to ask any questions about what you have read if you need further clarification.


Therapy is a process, which relies heavily on building a trusting relationship between therapist and client. This takes time in order for a person to open up and for the therapist to understand what he or she is struggling with. In order to do justice to the therapeutic alliance, one needs time to be in a process that is going to bring you long term change, therefore. If you are looking for short term work, then I may not be the right therapist for you.


In general, one of the most important rights the person seeking therapy has involves confidentiality.  Information revealed by a client during the sessions will be kept strictly confidential and will not be revealed to any other person or agency without written permission.

In order to maintain professionalism, therapists are required to be supervised by another therapist during these interactions, client anonymity is paramount.

Clinical supervision, where the supervisor is bound by the same code of ethic.

If you are at risk of seriously harming yourself or others or of being harmed, I am bound by our code of ethics to break confidentiality. However, this would only be done in extreme circumstances and I would always endeavour to discuss it with you before taking action.


It is helpful to remember that our relationship is professional and not social. Our professional relationship is of utmost importance as we work together towards achieving your goals. I am available Monday to Friday from 9am to 5pm and will respond to you as soon as I can.


All therapy comes to an end.  It is most beneficial for ending to be mutually agreed rather than a one-sided or impulsive action.  If either of us feels it is time to close the therapy we will discuss this.

If you decide to finish you may find yourself wanting to do that quickly, however the leaving period is part of the therapy work.  It is important wherever possible to allow a period of time before ending, in which to close the therapy, to review what has taken place and complete anything left over from our work together. I strongly advise allowing a minimum of two weeks for this. 

Please feel free to raise questions about this contract or any procedures you do not understand or feel unhappy about.


Sessions last 50 minutes.  I require 48 hours cancelation notice prior to the session, if appointments are not cancelled within this time frame, then fees will still be due. Please note I work in conjunction with the school term and break in school holidays.


Fees are £75, per session, this is payable by cash at the end of each session. Or if you wish to pay by bank transfer please do so before the start of each session. I will supply you with my bank details prior to the first session.


Please understand that I am not a crisis service. In the event of an emergency pls contact your GP or go to your local A&E or call 999.


Please contact me if you will not be able to keep an appointment. I require 48 hours’ notice of cancellation. if the appointment is not cancelled within the 48-hour period I would expect the full fee of the missed appointment.


My practice is in compliance with the Data Protection Act 1998 and all subsequent updates, including the new General Data Protection Regulations 2018 with effect from 25th May. By taking up my service, you agree to this policy and give your consent for me to hold your details on file in compliance with GDPR and confidentiality policy.


You will be required to wear a mask and use anti bacterial gel on enterring. If you have any signs or symptoms of Covid 19, then please refrain from attending therapy and follow the government guidelines in relation to COVID – 19.


By your signature below, you are confirming that you have read and understood this contact. Please return this form to me as soon as possible.



Contact number:


Email address:


in the event of an emergency; please fill in below name and contact number:



Diagnosed conditions or medication:


GP surgery:


Print Friendly, PDF & Email