Register For A Drop In

Registration Form

1. First Name

Last Name

2. Date Of Birth

3. Address Line 1

4. Address Line 2

5. City

6. County

7. Postal Code

8. NHS Number

1. Who is booking the session?

2. Have you been advised to make this referral?

Yes No

If yes, by who:

1. Is the young person aged 16 or over?

Yes No

2. How would you like us to contact you about the session?

1. Young Person Contact Number

2. Young Person Contact Email

3. Parent/Carer Full Name

4. Relationship to the child or young person

5. Parent/Carer Contact number

6. Parent/Carer Contact Email

1. What type of session is this booking for?

2. Session Name

Creative CYP Drop in (5-10 year olds) – Thursday 16th April Creative CYP Drop in (5-10 year olds) – Friday 17th April Creative CYP Drop in (11+ year olds) – Thursday 16th April Creative CYP Drop in (11+ year olds) – Friday 17th April

1. Is there anything you would like us to know before the session?

1. I understand this is a support session and not a full assessment or ongoing therapy, and that the information provided is used to enable access to the session.

Yes

2. If the young person is aged 16 or over, I understand they can choose whether or not a parent or carer is contacted.

Yes

3. I consent to Medway Therapeutic Alliance storing and using this information to create or update a client record, to support current and future care.

Yes

If we are worried about someone’s safety, we may need to share information to help keep them safe.