This offers transparency around how I work

And seeks your consent ...

  • Request For Consent
  • Private
  • Scope
  • Name
  • Home

Please complete this form together

We/I have requested the relationship couple session(s).

Confidentiality (Keeping things private)

All we discuss is confidential. We consent to the exceptions as listed in the disclosure document to allow for supervision and safety

Scope of Practice

I have read, and agree to, the Scope of Practice, at , and I consent to the scope of practice provided by The Practitioner.

I have read and understand the Disclosure Statement at and agree to this

Partner 1

First-Name & Last-Name



Partner 2

First-Name & Last-Name




Number & street




I agree to give 4 hours notice when rescheduling or cancelling appointments.

I agree that late cancellations, missing my appointment, not showing up, or rescheduling within 4 hours of the session time is deemed a chargable at 40% of the session rate.

I understand and agree to conditions for rescheduling, late cancelling and non-attendance.