New Client Intake

Client Intake & Consent

Name: Daniel Avital Psychotherapy
Price range: ££

For clients I’ve arranged to begin working with. Please complete this before your first session — it takes about five minutes.

This form gathers the practical details we need to start well — how to reach you, an emergency contact, and a few lines about what brings you to therapy. There’s no need to write at length; we’ll explore everything together in session.

Your answers are sent directly to me and held in strict confidence, in line with the BACP Ethical Framework and UK GDPR. This page collects some health-related information, so please complete it only once we’ve agreed to work together. Full detail is in my Privacy Policy.

Full name *

Date of birth *

Email *

Phone *

Home address *

Emergency contact — name *

Emergency contact — phone *

GP name & surgery *

What brings you to therapy? *

Anything else I should know? (optional)

Therapy Agreement & Consent

Please read the agreement below. Ticking the boxes and signing at the end confirms you understand and accept these terms.

Purpose of Therapy

Therapy is a confidential space for you to explore personal difficulties, emotional challenges, or relational problems in a safe and non-judgemental environment. The therapeutic process aims to support self-understanding, growth, and positive change.

Appointments & Fees

Sessions last 50 minutes and are typically held weekly. The fee per session is £95 for individual therapy and £120 for couples therapy. Fees are payable by bank transfer, cash, or online payment before or at the time of each session.

Cancellation Policy

Where possible, please give at least 24 hours’ notice if you need to cancel or reschedule. Sessions cancelled with very short notice may be charged, though exceptions are always considered with compassion — life happens, and I will always try to be flexible where I can.

Confidentiality

All information shared in sessions is confidential and will not be disclosed without your consent. The only exceptions are:

If I believe you or someone else is at serious risk of harm.
If I am legally required to disclose information (for example, under the Terrorism Act or Child Protection legislation).
If subpoenaed by a court of law.

I discuss my clinical work in professional supervision as required by the BACP. Your identity is protected throughout this process. This information, and any information you share, is handled in line with my Privacy Policy and UK GDPR.

Use of Phones & Devices

Please ensure your phone is turned off or silenced during sessions. I will do the same.

Ending Therapy

You may choose to end therapy at any time. Ideally, we will discuss and agree a planned ending, which includes a closing session to reflect on the work and provide a sense of closure. Where appropriate, I will support you in finding alternative support.

Ethical Practice

I am an accredited member of the British Association for Counselling and Psychotherapy (BACP) and work in accordance with their Ethical Framework for the Counselling Professions.

By ticking the boxes below and signing, you confirm that you have read and understood this contract and consent to engage in therapy with Daniel Avital.

Full name (type your name to sign) *

Today’s date *

Please avoid sharing anything you’re not ready to — there’s no requirement to give detail here. If you’d rather send this another way, just email me at daniel@attune-therapeutics.uk.

Thank you

Your intake form and signed therapy agreement have been sent to me — thank you. I’ll be in touch to confirm, and we’ll take everything else at your pace when we meet.

Almost there

The automatic send didn’t go through. Your email app should have opened — if it didn’t, copy your details below and email them to daniel@attune-therapeutics.uk.