The Neuro Therapy Place Client Registration Form

The Neuro Therapy Place Registration Form

To understand your individual needs and to offer you the most suitable therapies, we kindly ask you to provide some personal and health-related information. This information will be processed exclusively by our staff and will be securely stored in our client database and record-keeping systems. Please note that oxygen therapy is available for adults and children aged 13 and older.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

Personal Contact Information

We'll use this information to get in touch with you about accessing our services.
Title
First name
Surname
Date of Birth

DayMonthYear
Street address

Street Address

Street Address Line 2
CityState / ProvincePost Code
Email
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: 00000000000.
Home Phone Number

Area CodePhone Number

Emergency & Medical Contact Information

We collect this information so we can contact someone on your behalf in an emergency, and liaise with your GP where relevant to your care
Emergency contact name
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Please provide details of your GP Surgery

GP Surgery name

Street Address Line 2

CityCounty

Post Code
GP phone
Please enter a valid phone number.Format: (000) 000-0000.

Access & Mobility

We ask for this information so we can make any adjustments needed to support your access, communication, or participation to ensure you can access our services safely and comfortably.
Do you have any support requirements?
Please select all that apply
Where necessary, we may put in place a Personalised Emergency Evacuation Procedure (PEEP) to ensure we can support you safely in the event of an evacuation or other emergency. This may include the use of a hoist, wheelchair, mobility aid, or other appropriate procedures, depending on your needs.
I understand that a PEEP may be required for me to access our services, and I agree to take part in developing one if needed.

Services Selection

Please choose the primary service/s you are most interested in accessing with The Neuro Therapy Place.
Are you an existing client
Have you attended the Neuro Therapy Place in the six months?
Has any of your medical information changed since your last visit?
Please select the service you are interested in

Your Health Condition

We ask for this information to support your access to our services. Please provide information on your current health conditions that may be diagnosed or awaiting diagnosis.
Start typing the name of a condition to search and select.

Please note you can select up to 5 primary conditons.

If you do not have an exsisting health condion please select None.
Search for your Health Condition
Additional Information

0/100
Have you seen a specialist consultant for your condition(s)?
Have you discussed attending the Neuro Therapy Place with your consultant?
Is your consultant supportive of your attendance?

Medication & Treatment

Before starting with our services, we need to check that it's safe and suitable for you. The questions below help us identify these before your first session
Please provide up-to-date information on your current medications, including any herbal remedies or supplements you are taking and how often. If you prefer, you may upload a document with this information using the file upload below.
File Upload

If you would prefer, please upload a document showing the current medication you are prescribed.
Cancelof

Physiotherapy

To help our Physiotherapist plan a session tailored to your specific needs, please provide the following details.
NHS Number
Referring NHS Service or Clinician
Mobility Status
Activity Level
Transfer Ability
Are you currently managing chronic pain?
Do you have ongoing Balance Problems
Have you had any falls in the last 6 Months

Physiotherapy Classes

To access our specialist Physiotherapy classes, all clients are required to be reviewed by a physiotherapist before attending. Please note that spaces are limited and allocated on a first-come, first-served basis.
NHS Number
Referring NHS Service or Clinician
Mobility Status
Activity Level
Transfer Ability
Are you currently managing chronic pain?
Do you have ongoing Balance Problems
Have you had any falls in the last 6 Months

Complementary Therapy

Our complementary therapy services are provided by external practitioners who offer services on set days at our centre.
Please indicate which service/s you are interested in

Final Questions & Signature
How did you hear about us?
We'd love to keep you updated. Please tick any of the below you'd like to receive from us:
Signature
Should be Empty:

The Neuro Therapy Place Registration Form