Adult Registration Form

Area(required)
—Please choose an option—BradfordLeeds

Your Name (required)

Date of birth(required)

Gender(required)
—Please choose an option—MaleFemaleOtherPrefer not to say

Address (required)

Postcode (required)

GP/Medical centre (required)

Phone number (required)

Are you coming to Relate with a partner or young person? If Yes, please give details, such as: Name, DoB, Address, Postcode and GP. (required)

If you have a voicemail option on your phone and you are happy for us to leave a message please tick. (required)
YesNo

Do you consent to us sending text messages? (required)
YesNo

We will contact you regarding appointments via email, so please ensure that you check your emails on a regular basis.
Email (required)

Our offices are on the first floor with access via stairs, please tick the box if you require access via a lift? (required)
YesNo

Do you have any language needs? If so please give details.

How would you describe your ethnicity? (required)
—Please choose an option—White - British/English/Northern Irish/ Scottish/WelshWhite - IrishWhite - Gypsy or Irish travellerWhite - Any other white backgroundAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British - Any other Asian BackgroundBlack/African/Caribbean/Black British - AfricanBlack/African/Caribbean/Black British - CaribbeanBlack/African/Caribbean/Black British - Any other black backgroundMixed/Multiple Ethnic Groups - White and Black CaribbeanMixed/Multiple Ethnic Groups - White and Black AfricanMixed/Multiple Ethnic Groups - White and AsianMixed/Multiple Ethnic Groups - Any other mixed backgroundOther Ethnic Group - ArabOther Ethnic Group - Prefer not to sayOther Ethnic Group - Any other ethnic group

If you selected other please specify.

How would you describe your religion?
—Please choose an option—ChristianHinduMuslimBuddhistJewishSikhAtheistNoneOtherPrefer not to say

If you selected other please specify.

How would you describe your sexual orientation?
—Please choose an option—HeterosexualBisexualGayLesbianOtherPrefer not to say

How much money comes into your household yearly? (required)
—Please choose an option—£0 - £5000£5000 - £10000£10000 - £15000£15000 - £20000£20000 - £25000£25000 - £30000£30000 - £35000£35000 - £40000£40000+

Do you feel your financial circumstances have a negative impact on your relationship?
—Please choose an option—YesNo

Do you currently receive any of the following benefits?
—Please choose an option—NoUniversal CreditHousing BenefitCouncil Tax reductionJob seekers allowance (including National Insurance Credits)Income SupportPension Benefits (including the state pension or pension credit)Tax creditsSickness or disability benefits (including PIP or ESA)Child benefitCarer's allowanceOther

If you selected other please specify.

Which of the following best describes your current employment status?
—Please choose an option—Working full timeWorking part timeSelf employedFull time studentRetiredUnemployedNot workingOther

If you selected other please specify.

Service required: (required)
—Please choose an option—Family counsellingIndividual and Couple Therapy for DepressionPsychosexual TherapyRelationshipYoung People's

What are your main reasons for contacting us? Please tick as many boxes as apply.
Improving communication between us.
YesNoPossibly
To help with conflict.
YesNoPossibly
Problems with our sex life.
YesNoPossibly
Rows and arguments.
YesNoPossibly
Money worries.
YesNoPossibly
Housing problems.
YesNoPossibly
My partners behaviour.
YesNoPossibly
My behaviour.
YesNoPossibly
Disagreements about housework.
YesNoPossibly
Managing our free time.
YesNoPossibly
Bereavement.
YesNoPossibly
Relationship with family and friends.
YesNoPossibly
Problems with religious beliefs.
YesNoPossibly
Having a baby.
YesNoPossibly
Disagreements about parenting.
YesNoPossibly
Problems at work.
YesNoPossibly
Unemployment.
YesNoPossibly
Violence and/or abuse.
YesNoPossibly
Physical health problems.
YesNoPossibly
Mental health problems.
YesNoPossibly
Alcohol/drug dependency.
YesNoPossibly
Taking each other for granted.
YesNoPossibly
Worried about whether our relationship will end.
YesNoPossibly
Other.
Other

If you selected other please specify.

Important information relate
To be read before your first meeting with a counsellor the relationship people
Confidentiality
Relationship support is a private and confidential form of help. We hold information about each of our clients and the services they receive in confidence. This means that we will not normally give your name or any information about you to anyone outside the organisation. However, there are exceptional cases where Relate might ethically or legally have to give information to relevant authorities, for example if we had reason to believe that someone, especially a child, is at serious risk of harm or to prevent a miscarriage of justice. We will discuss any proposed disclosure with you unless we believe that to do so could increase the level of risk to you or to someone else.
If you come to counselling with a partner or your family, the counsellor may suggest seeing each of you individually. It is important for you to know that what is said in those individual sessions will be confidential and not shared with your partner or family.
If you attend a course or group work programme, confidentiality will be discussed at the first session.
Reports and client records
Occasionally Relate is asked by our clients or by external agencies such as Social Services or the NHS to write reports on the progress made in counselling or other services. We are not normally in a position to do this because of our duty of confidentiality to our clients and because Relate practitioners are not trained in the specialist areas of diagnosis or social work assessment. However, we can in some circumstances, and on receipt of written consent from the client(s) who attended a service, provide brief information about the dates and number of sessions attended. In addition we are also asked by clients, their solicitors, the police and the courts for access to the client records. These are not suitable as evidence in legal proceedings and Relate reserves the right to resist legal requests to produce the records in court. We do this in order to protect Relate’s duty of confidentiality to all its clients and to preserve Relate’s national reputation as the provider of confidential counselling and relationship support.
Data protection
The information about confidentiality in no way contravenes your rights under the General Data Protection Regulation May 2018 to access personal data that Relate holds on you. Relate keeps confidential records and statistics about its clients. All records are kept securely and are only seen by authorised Relate personnel. These records are subject to the General Data Protection Regulation May 2018. Some of the information we may collect is classified as sensitive personal data and we can only use such data where we have your explicit consent. This data may include: racial or ethnic origin, political opinions, religious beliefs, trade union membership, physical or mental health, sexual life, criminal proceedings and offences. Your personal and sensitive personal data will only be used in order to provide the service to you and for managing and quality assuring the service. Records are kept for a period of 7 years and are then destroyed. Important information relate
To be read before your first meeting with a counsellor the relationship people
Relate recognises that on rare occasions our clients may wish to exercise their rights under the General Data Protection Regulation May 2018 and make a subject access request in respect of their personal information held by Relate. Often during counselling and in services, information is provided by more than one individual. In these cases, Relate will only release information if all of the individuals involved have given consent. If at any time, you wish to exercise your right under the Act you should put your request in writing to the Service Manager and provide evidence of your identity such as a copy of your passport or driver’s licence and proof of your address. When the Service Manager receives your written request and evidence of identity, they will respond to your request within one calendar month. Relate’s response to a valid subject access request will normally be in the form of a schedule listing and describing the personal data we hold on them.
By signing the consent form you acknowledge that you understand and agree with Relate’s subject access policy.
Privacy
Mobile phones
Please switch off your mobile phone during your sessions as it can create an unhelpful distraction and interruption.
Unauthorised electronic recording
In order for you to work safely and effectively with a practitioner, it is important that the privacy of the work is respected. Please, therefore, do not attempt to record your sessions using any device or app. If it is found that recordings have been made covertly, services for the individual responsible will be discontinued immediately and Relate reserves the right to seek legal advice regarding possible further action.
Authorised electronic recording
Occasionally a practitioner, for example one who is undertaking a training course, will be required to record a session with a client or clients. Some practitioners regularly use audio or video recording in their work and in these circumstances, you will be asked to give your written consent for this to happen. The consent will specify all the ways in which the recording will be used (for example training, supervision or research) and will specify how and when the recording will be destroyed.
Domestic abuse
Domestic abuse is an issue for many people who come to Relate for help with their relationship. We know from our experience that in this situation, working with couples or family members together may not be safe. If this is so, the counsellor will help each person to get individual specialist support from Relate or another agency.
Cancellation policy
If you intend to cancel, at least 48 hours’ notice should be given to avoid cancellation charges. Please contact your Relate Centre for further information.
Codes of ethics and practice Important information relate
To be read before your first meeting with a counsellor the relationship peaple
All Relate counsellors and supervisors are required to comply with the code of ethics and practice that is appropriate to the work they undertake.
e Relationship counselling is covered by the British Association for Counselling & Psychotherapy’s Ethical Framework for Good Practice.
e Sex therapy is covered by the College of Sexual and Relationship Therapy’s Code of Ethics & Principles of Good Practice.
e Family counselling is covered by the Association for Family Therapy’s Code of Ethics & Practice.
In addition, all Relate personnel must comply with Relate’s practice policies and guidance which both complement the external codes and set specific organisational standards for ethical working. Please ask your practitioner if you would like to know more about this.
Relate is a national trainer of relationship counsellors. All our practitioners in training have been assessed as competent to work with their clients on a wide range of issues. As with all our counsellors, they are in ongoing professional clinical supervision for the work they undertake. This assists them to offer you maximum help and support. If you would prefer not to be seen by a practitioner in training, please let the centre know.
Feedback and complaints
If you have any feedback about the service you received at Relate, or you are not satisfied with your experience, please tell the Service Manager, the counsellor or another member of staff. It is possible the Service Manager can resolve your complaint, but if you wish to take things further, Relate has a complaints procedure which the Service Manager can give you details about. Relate welcomes feedback and if you make a complaint, we will always take it seriously as it allows us to improve the service we offer to our clients.
Confidentiality Statement
Relate offers confidential counselling to all our clients. We will not share information about you with anyone outside Relate unless we have reason to believe that either you or someone else is at serious risk of harm. We will discuss any proposed disclosure with you unless we believe that to do so could increase the level of risk to you or to someone else.
I have read and understood Relates Confidentiality statement.

Data Protection Statement
I consent to Relate* using my personal and sensitive personal data in accordance with the
General Data Protection Regulation May 2018 for the purposes of delivering counselling to me, and for quality assuring, and assessing the effectiveness of those services.
I consent to Relate using anonymized information to improve their services.
I consent to Relate telling me about other services that might interest me.
I consent to Relate using anonymized information to improve their services.
I have read and understood Relates Data Protection statement.

Cancellation policy
I have read and understood Relates Cancellation Policy.

Name

Date

If you are coming with a young person please complete the Young Person Data Protection form after this one.

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