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?

- Select Option - Yes No

If yes, by who:

1. Is the young person aged 16 or over?

- Select Option - 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. Select the Creative Drop In Session (Friday 29th May)

- Select Option - 11am-12pm (Ages 5-10) 2pm-3pm (Ages 11+)

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.