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Registration Form

Personal Detail

Date of Birth
Day
Month
Year

Emergency Contact Details:

GP Information

Payment information

Single choice
Self-funding
Insurance

Your Resilient Mind Ltd is compliant with all data protection regulation and has a commitment to ensure your privacy, by constantly reviewing our Privacy Policy, to ensure that we are in line with all relevant legislation.

Your Resilient Mind Ltd shall send relevant emails only to its clients, such as appointment confirmations, reminders, invoices and payment queries, as well as content relevant to the services we are providing.


To indicate your consent, please sign this document as follows:

I hereby consent to Your Resilient Mind Ltd storing my personal information within the registration form (Page 1), the questionnaires I complete as part of my engagement with the clinic, any relevant documents I shall send to the clinic as part of the services I receive from the clinic, as well as the clinical notes the clinicians will keep as part of the services they are providing to me. Should I not consent to the above, I shall express in writing which aspects of this form I do not consent to, whilst acknowledging that this might cause the clinic to not be able to offer some or all the services relevant to me.

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