Client Contact Information | Tanya Thomas Therapy

Printed Name *

Birthdate *

Post Code *

Home Phone

May a message be left on this home number?

Yes
No

Mobile Number

May a message be left on this mobile number?

Yes
No

Work Number

May a message be left on this work number?

Yes
No

Email Address *

This is my preferred contact to send details of treatment plans, any therapeutic tasks or therapeutic audio’s will be send this way.

Please check One of the Following Three Statements: *

I give consent for Tanya Thomas Therapy to use the email above to correspond with me in all matters directly related to the provision of services (including invoicing, appointment bookings, confirmations, and reminders: follow-up services; invitations to complete feedback surveys, etc.) This consent applies to any new or updated email address that I provide to Tanya Thomas Therapy in the future.
I have not provided my email address in this consent form, but I understand that if I were to send an email to Tanya Thomas Therapy in the future I am giving implied consent to Tanya Thomas Therapy to respond to that email, as often as needed, to address any inquiry.
I give consent to Tanya Thomas communicating with me through WhatsApp and WhatsApp chat. I understand that my number will be stored in her mobile phone until our contract terminates.

Would you like to be on my Monthly Email Newsletter List? (Please check one of the statements below):

Yes, I would like to receive monthly email
No, I would not like to receive monthly email

My monthly newsletter contains articles on physical, mental and emotional wellness, links to online resources and book recommendations as well as free advice and tips that you can use to improve your situation where ever you find yourself and notices of the latest thinking in each field and new services.

Referral Source: Please let me know how you learned about "Tanya Thomas Therapy". *

Please type your name below to agree to the above agreement *

Date *