Registration & Consent Form

Registration and Consent Form

Young Person's First name

Young Person's Last name

Young Person's Birthday

Day

Month

Year

Parent/Guardian's Full Name

Parent/Guardian's Email

Parent/Guardian's Phone Number

Address

Postcode

GP Surgery and Address (if known)

School Name and Contact (if relevant)

Other Services involved

How did you hear about Dr Ellie's practice?

Consent to Share Information with Other Professionals (if appropriate)

Yes

Consent to Keep Records

Yes

I consent to sessions being transcribed using Heidi AI, a secure, GDPR-compliant transcription tool, to support accurate record-keeping. No recordings are stored, & transcriptions are kept securely. Consent can be withdrawn at any time by emailing Ellie.

I give consent to the use of AI transcription

I do not consent to the use of AI transcription

I confirm I’ve read the Privacy Notice and consent to collection and use of personal and health data for psychological services under UK GDPR. I understand I can withdraw consent anytime by emailing ellie@drelliehambly.com.

I consent

I do not consent