ChangeUChoose Intake & Consultation Form Step 1 of 2 50% HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.PERSONAL DETAILS:(Required) First Last Preferred Name:(Required) Date of Birth:(Required) DD slash MM slash YYYY Address:(Required) Relationship Status: Occupation: Email Address: Telephone Number: Emergency Contact Name: Telephone Number: Health:Doctor’s Name and Address: Medication: HEALTH PROBLEMS/Medical Conditions (Past & Current):Addictions Drinking Smoking Drugs Gambling Compulsive Behaviour Concerns Anxiety Stress Fears Phobias Panic Attacks Guilt Relaxation Concerns Eating Problems Food /Diet Weight Problems Anorexia Bulimia Exercise Concerns Depression Confidence Self Esteem Motivation Achieving Goals Procrastination Concerns Career Issues Interview Skills Nerves Public Speaking Concentration Exams Memory Driving Skills Concerns Sexual Problems Fertility IVF Conception Pregnancy Birth Concerns Pain Control Hearing Sight/Vision Mobility Skin Problems Hair Growth Concerns Relationships Childhood Problems Sleep Problems Please Read The Privacy StatementConsent(Required) I agree to the privacy statement.PRIVACY STATEMENT ChangeUChoose Privacy Statement This is to inform you what data I am collecting from you and what I intend to do with it. What data do I keep and why do I need it? Name and age – this is basic information that helps me get to know you. Address, email address, phone number – I use this as a way of contacting you regarding your sessions. I will mainly use the method you first contacted me on but if I cannot reach you, I will try a different method. Next of kin/medical professional’s details – If I was worried that you were at risk then I may need to contact your next of kin or medical professional, if I can. I will let you know when/if I am going to do this. Session notes – I keep brief notes of our session(s), in a locked filing cabinet. Will I share your data and if I do, who will I share it with and for what purpose? It is very unlikely that I will share your data. I will not sell it on or use it for unethical reasons. I may have to share it if my notes are subpoenaed by court, if you or anyone you tell me about is at harm or risk of harm I may have to pass this information on. I may also discuss your case during supervision but I only use your first name. How will I store your data? It is mainly stored as hard copy in a locked filing cabinet. Immediately after the work is finished, I transfer the data with your initials to my password protected computer. Your phone number(s) may be kept in my business mobile phone with your first name and last initial. Only I will access your information. How long will I store your data for and how will I dispose of it? I will keep your details and session notes for the time required by my insurer. After this time I will destroy any document with your personal information and delete your phone number out of my mobile phone. Consent I consent to my data being used as set out above. 62929