University For You - Client Registration Form

University For You - Client Registration From
Please provide where possible the information required below. Before clicking 'submit', you can print a copy for your records. U4U will not share any of the information you provide with third parties without your expressed permission. This form can be completed by the student (the Client) and/or their parents/guardian.
Client Information
Name
First NameLast Name
Age
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
What do you consider to be your first language?
Do you speak any other languages? And to what degree (e.g. beginner, conversational, fluent)?
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Email
example@example.com
Please provide the name of your university
What course will you be studying at university?
How long is your course?
Parental/Guardian information
Parent/Guardian 1 - Name
First NameLast Name
Relationship to you
Address (if different from client's home address)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Area CodePhone Number
Parent/Guardian 2 - Name
First NameLast Name
Relationship to you
Address (if different to previous addresses stated)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Area CodePhone Number
Health
Current GP/Health Centre
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Will you register with a GP closer to university?
Are you, or have you been, on any medication for general health conditions (e.g. asthma, diabetes, allergies etc.)
If answer to previous question is 'yes', please state the health condition(s) and the medication prescribed
Do you, or have you ever suffered from the following?
Other
If you have ticked any of the above, please provide details of the following: (1) Are symptoms ongoing? (2) If in the past, how long ago? (3) Are you on any medication for any of the above-mentioned conditions? (4) What symptoms do you experience and their severity?
Education
Have you been diagnosed with any of the following?
Other
Have you ever been seen by the following professionals?
Are there reports available?
During your time at school, did you ever have an Education Health and Care Plan?
If you answered 'yes' to previous question, at what age(s) and for how long?
List all senior schools attended (and years of attendance)
What do you consider to be your academic strengths and/or weaknesses?
Did you have difficulty with any academic subjects during senior school? Please describe.
Please provide details of A/As-level/ IB results
Rows Predicted Grade Grade
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
Did you have to resit any A-levels? If so, please provide details
Did you have any special exam arrangements/access arrangements/ accommodations? If so, please describe
Did you receive any extra tutoring throughout your A-levels? If so, please provide details

Please provide details of GCSEs

Rows	Grade
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]
[Insert Subject]

Did you receive any extra tutoring throughout your GCSEs? If so, please provide details
Did you have to resit any GCSEs? If so, please provide details
Did you have any special exam arrangements/access arrangements/ accommodations? If so, please describe
Confidentiality
It is important to be aware that any information provided by you, the student, during your time with U4U will remain confidential and will not be shared with your parent(s)/guardian(s) without your expressed permission.

However, in the event that we become concerned about your safety and/or wellbeing, we will make your emergency contact aware but will discuss this with you first.
Name of emergency contact
First NameLast Name
Relationship to you
Phone Number
Area CodePhone Number
Email
example@example.com
By signing below, you and your parent/guardian confirm that you agree with the above terms regarding confidentiality.
If you require more information before signing, please email office@psychology4.com
Client Signature
Clear
Parent/Guardian Signature
Clear
Additional Information
Is there anything else you would like to tell us?
How did you hear about us?
Should be Empty:

University For You - Client Registration From

Client Information

Parental/Guardian information

Health

Education

Confidentiality

Additional Information