top of page

Earth Wisdom Therapy

info@earthwisdomtherapy.co.uk

HOME
Reduced-Cost Counselling
Ecotherapy
About Us
Funding
Bookings
More

Use tab to navigate through the menu items.

Earth Wisdom Ecotherapy Community Interest Company

Therapy Agreement Consent Form

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

First name*

Last name*

Phone*

Email*

Date picker*

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.

GP Name*

GP Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship To You*

Earth Wisdom Ecotherapy Community Interest Company

Client Demographics Form

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

First name*

Last name*

Address*

How did you hear about us?*

Age*

18 - 24yrs

25 - 34yrs

35 - 44yrs

45 - 54yrs

55 - 64yrs

65yrs & Over

Gender*

Male

Female

Non-binary

Prefer not to say

Other

Marital Status*

Religious or Spiritual Affiliation*

No Religion

Christian: Church of England, Roman Catholic, Protestant (e.g Methodist, Baptist), Orthodox (e.g Greek Orthodox, Russian Orthodox), Other Christian

Buddist

Hindu

Jewish

Muslim: Sunni, Shia, Other Muslim

Sikh

Pagan: Wiccan, Druid, Heathen, Other Pagan

Other

Employment Status*

First name

Last name

Email*

Write a message

Rooted in Care. Grounded in Nature.

bottom of page