Intake & GDPR form

Please complete and submit the form below prior to your first session.

First name

Last name

Date of birth

Day

Month

Year

Mobile number

Current home address

Occupation

Next of Kin (for emergency use only)

GP details

Medication: Please include all medication you are taking, why you are taking it, how long you have been taking it, side effects, how long you anticipate taking it. Please include any alternative medication you are taking

Reasons for seeking therapy at this time

I understand Kerry-Lyn Stanton-Downes works in a multi disciplinary manner and give her permission to contact any and all health professionals I am working with, or may potentially work with during the course of my therapy with her. I understand that Kerry-Lyn will talk with me directly before contacting any professional so that I fully understand the reason for her contacting them and have the opportunity to reflect on whether it is the right time in my therapy process.

Please list all health professionals you are currently working with - including psychiatrists, function medicine doctors, nutritionists, physiotherapist, osteopaths, energy healers etc and what you are working on with them.

I confirm the information provided above is, to the best of my knowledge, correct and up to date. By submitting this form I give permission for this information to be securely stored with Connected Life Limited.

I confirm I have read and agree to the Booking Terms as laid out on the New Patient Information page.