Subject Access Request Form

Full name

Phone

Email

Name of your counsellor

What is your client reference (if known)

Name of referrer (if your sessions are being funded for you)

Please confirm which information is required

Full name

Date of birth

Address

GP details

Presenting issues (as stated on referral)

Session dates

Self-funded or referring party information

By submitting this form, I confirm that I understand counselling session notes will not be released and consent to the requested personal information being shared with me via email

Subject Access Request Form