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Client Intake and Consent Form

About You

Personal Information

Medical Information

Do you have any existing medical conditions?

Have you ever been diagnosed as suffering from any psychological or psychiatric conditions?

Are you taking any prescription drugs?

Do you drink alcohol?

Do you smoke or vape?

Do you or have you ever used any recreational drugs?

Are you receiving any specialist care or treatment of any kind?

Do you experience any of the following?

Heart problems

Migraine

Epilepsy

Physical pain

Fears or phobias

None of these

Emergency Contact

Please provide the name and telephone number of someone I can contact in case of emergency

Data Consent

The GDPR (General Data Protection Regulations) state that I must obtain consent from all clients to store and use their personal data. Before you provide your consent, I will confirm what information I will hold about you and how I am permitted to use it. Please click on the link below and you will be taken through to my consent form.

Data Privacy Policy

When you become a client of Samantha Shanks-Husbands at Prepare to Win, you will be required to share personal information. This document outlines the personal data that will be collected and advises how that data will be processed. I collect and store data in line with the terms of GDPR.

The Data I Will Collect and Store About You

I will ensure that the personal data I gather is limited to only what is necessary to offer my services, to invoice and receive payment from you and to provide you with information via telephone and email where necessary. I will collect and store the following data:

Your name
Gender
Occupation
Date of birth
Postal address
Email address
Telephone number(s)
Details of your GP
Medical history
Therapeutic issues
Case history
Ongoing treatment records
Payment preferences
Details of someone I can contact in case of an emergency

Your rights with regards to your personal data are as follows:

The right to be informed
The right of access
The right to rectification
The right to erasure
The right to restrict processing
The right to data portability
The right to object
The right not to be subjected to automated decision making

How I Will Use Your Data

I will limit my use of your personal data to storing identifiable records of our sessions to administer your client programme, to enable me to contact you in between our sessions, and where necessary to conduct follow up emails and phone calls to follow your progress.

I will ensure my client records are up to date and accurate and will rectify any errors as soon as they are brought to my attention.

Please be advised that in order to comply with the terms of my insurance I am required to keep my client records for a minimum of seven years, following the last occasion on which a session was given. In the case of treatment of minors, I have been advised that my records should be kept for a minimum of seven years after they reach the age of eighteen. This is because the statute of limitations in the UK, which is the time during which an individual is allowed to bring a claim, is six years for certain injury claim situations, or six years after the individual reaches the age of majority in the case of minors.

I will ensure that my client records are only stored on software which is GDPR compliant, on a device that is password protected. I do not keep paper records.

Sharing Your Data

I may only share your data if you give me your written consent to do so. I will only share it with a suitably qualified professional or practitioner to whom you have asked me to refer you. However, I will share your data with appropriate agencies or people in the case of welfare/safeguarding issues that are governed by statutory obligations. Any data that I share will be done electronically. It will be encrypted and password protected.

Deleting Your Data

I will securely delete electronic records. I will also securely destroy any device that I used to store your data once that device comes to the end of its useful life.

Your Data Consent

By signing this form you give me permission to collect the personal data specified above. You agree to receiving email correspondence, text messages and telephone calls from Samantha Shanks-Husbands of Prepare to Win, as agreed upon during our sessions. You can withdraw this consent at any time in writing, by letter or email. If you do this, I will securely destroy all of your data; except in cases where doing so would compromise any ongoing statutory process. If you have any further questions about my data policy, please ask me.

Confidentiality

All information, whether verbal or written in notes, is treated as strictly private and confidential.

Samantha Shanks-Husbands has a responsibility both to the client and to the community at large. Some moral and legal limitations therefore apply to confidentiality. These limitations mainly concern risk of serious self-harm, harm to others and child protection issues. If a situation arises in which the moral or legal limits of confidentiality are exceeded, the reasons will be explained by the therapist and discussed with you at the time.

Client Declaration

The information I have given here is to the best of my knowledge full and correct. I undertake these sessions on the understanding that it is a collaborative process and that progress depends in part upon my own motivation and participation. I understand that there are no guarantees offered and that my success very much depends on my own willingness to participate in the therapeutic process.

I have read and agree with Prepare to Win's terms and conditions

(Accessible at https://preparetowin.co.uk/terms)

After you have signed this document, you will automatically be directed to your client assessment. You will also find a link to your client assessment, in the email confirming that you have signed this form.

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October 16, 2021 7:24 pm BST

Client Intake and Consent Form Uploaded by Samantha Shanks-Husbands - sam@preparetowin.co.uk IP 10.0.0.2