Registration - Old version

Personal Details

Name *

First

Last

Email *

Date of Birth *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Primary Contact Number *

Secondary Contact Details eg Mobile Phone

Next of Kin/ Emergency Contact Name *

First

Last

Next of Kin/ emergency contact number

GP Name *

First

Last

GP Contact Number

Do you consent to us leaving voicemail messages? *

Yes
No

Do you consent to us corresponding with you using the email address provided *

Yes
No

Employment Details

Employer Code (where applicable)

Employer Name *

Your Current job Title *

Current Health and Wellbeing

Are you registered disabled? *

Yes
No

Health Conditions: If you checked any of the boxes in the previous section please use this field to give further details

How much has the COVID-19 pandemic Negatively affected you in the following *

	Not at all	Slightly	Definitely	Markedly	Severely
Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc)	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Not at all	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Slightly	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Definitely	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Markedly	Mental wellbeing (eg. Stress, mood, anxiety, Optimism, helplessness etc) Severely
Work (eg, motivation, concentration, attendance, meeting deadlines etc)	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Not at all	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Slightly	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Definitely	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Markedly	Work (eg, motivation, concentration, attendance, meeting deadlines etc) Severely
Private leisure activities (doing things alone such as reading, walking, hobbies etc)	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Not at all	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Slightly	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Definitely	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Markedly	Private leisure activities (doing things alone such as reading, walking, hobbies etc) Severely
Relationships (forming and maintaining close relationships including with those who you live with)	Relationships (forming and maintaining close relationships including with those who you live with) Not at all	Relationships (forming and maintaining close relationships including with those who you live with) Slightly	Relationships (forming and maintaining close relationships including with those who you live with) Definitely	Relationships (forming and maintaining close relationships including with those who you live with) Markedly	Relationships (forming and maintaining close relationships including with those who you live with) Severely

How do you feel about returning to normal life and what are your immediate plans? *

What have you learnt in lockdown and what lifestyle changes are you planning to make? *

Availability

Please specify any days you would available to attend a one to one session. Our opening hours are 8am - 9pm every day. (please check all that apply)

File Upload

Click or drag a file to this area to upload.

Confidentiality

Confidentiality AzuraMinds takes confidentiality and data protection extremely seriously and we manage, store and use your personal data for the purposes of your treatment only. We ensure complete confidentiality throughout any contact with AzuraMinds, whilst responding appropriately to any situation where there is a risk of harm to self or others, as we are legally required. Data Protection By signing this form I consent to relevant information about my condition and treatment being shared between a multi-disciplinary team of health professionals at AzuraMinds involved in my care. Once form is completed Thank you for contacting us. We will be in touch within the next 3-5 days to arrange your AzuraMOT.

Data Protection

By signing this form I confirm that I understand that a multi-disciplinary team of health professionals at AzuraMinds may be involved in my care and will share relevant information about my condition and treatment.

Please check this box to confirm that you have read and agree to the Confidentiality and Data Protection Statements above *

I have read and agree to the Confidentiality and Data Protection statements above

Please check the box below to confirm that you understand that any AzuraMOT appointments cancelled less than 48 hours prior to the arranged appointment time and date will be charged at full rate *

I understand and accept that I will be charged at the full rate for the appointment if cancelling less than 48 hours before the scheduled appointment time.

Signature *

Thank You for completing our registration form. We will contact you within 3-5 working days to arrange your first appointment

Registration – Old version

Personal Details

Employment Details

Current Health and Wellbeing

Availability

Confidentiality

Data Protection