The Embodied Mind is Edmund Mulligan.
enquiries@embodied-mind.org +44(0) 7921 350 779

Register for Therapy

21 February 2022
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  • Personal and Contact Details
  • Medical History
  • Consent

Personal and Contact Details

The details collected on this page allow me to know who you are, how to contact you and why you are seeking treatment from me.

This will be used in place of your name in case study reports. You can either use your initials, or for additional privacy choose a code of up to eight letters and numbers. You can also use this code to log into the web site.
Password must be at least 7 characters long.
Password must be at least 7 characters long.
Please select the type(s) of therapy you are registering for. This is indicative only - you can change your mind after an initial consultation.
Please specify the type of therapy you require. Note that if I am not qualified in this, I may refer you to another therpist or help you explore alternatives that I am able to supply.
Address Line 1  *
Address Line 2
City  *
State or Region
Country  *
Zip  *
Your occupation, or Student, Retired, etc.

Medical History

The details collected on this page allow me to check for any contraindicators to the treatment you are requesting, and enable me to advise you on how to proceed if there are.

Consent

This confirmation page allows you to state that you consent to the treatment you are requesting and to my collecting the data nacessary to provide that treatment effectively and safely. You may withdraw cnsent at any time, although I request you discuss this with me first, if that is possible.

My Terms and Conditions
My Privacy Policy
Yes

Register as Therapy Client

21 February 2022
0 Comment
Uncategorised
This will be used in place of your name in case study reports. You can either use your initials, or for additional privacy choose a code of up to eight letters and numbers. You can also use this code to log into the web site.
Please select the type(s) of therapy you are registering for. This is indicative only - you can change your mind after an initial consultation.
Address Line 1  *
Address Line 2
City  *
State or Region
Country  *
Zip  *
Address Line 1  *
Address Line 2
City
State or Region
Country
Zip
Password must be at least 7 characters long.
Password must be at least 7 characters long.
Yes

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