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Consent Form & Demographics 

Please complete the form below to confirm that you have read, understood, and agree to the Therapy Rooms Painswick Therapy Agreement. Engaging in therapy indicates your consent to the terms. Completing this form provides formal acknowledgment of the agreement and is an important part of ensuring safe and ethical practice.

Therapy Rooms Painswick

Therapy Agreement Consent Form

Tel: 07871 154539

Email: info@therapyroomspainswick.co.uk

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

Date
Day
Month
Year

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.

Therapy Rooms Painswick

Client Demographics Form


Tel: 07871 154539

Email: info@therapyroomspainswick.co.uk


Capturing client demographics helps us tailor our counselling services to better meet individual needs, ensuring that we provide the most relevant and effective support.

How Did You Hear About Us
Age
Gender
Male
Female
Other
Marital Status
Ethnicity
Religious or Spiritual Affiliation
Employment Status
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