Terms and Conditions

This form is the expression of my voluntary and informed consent to engage in professional social work services, in the context of a psychosocial interview. I understand that I may withdraw from the social work service at any time.  Further, I understand that information and records are kept in a secure and confidential manner.

I further understand that following my conversation with Your Counselling Ltd/ Jeffrey Sturgeon a summary report will be made available to the fertility clinic, or the consultant agency, that I am working with. I understand that the summary report then becomes the property of the fertility clinic and any further disclosure of the aforementioned report will be made in accordance with their disclosure policies.

I understand that Your Counselling Ltd. does not retain copies of the report but rather the intake notation and information only. I further understand that the summary report will be transmitted to the clinic. via a PDF document and attached to an electronic mail message. Further to this, I release Jeffrey G. Sturgeon
with any liability associated with further transmission and disclosure. 

I understand that should I wish to obtain a copy of the report I will have to request it from the referring agency and or clinic. 

By selecting the box and typing my name below, I understand that it is if I am signing in person.  I further understand that consent will be verbally reviewed prior to engagement in any social work intervention.

Check to confirm completion of this report to the best of your knowledge.