background image
7th April 2020 

Privacy Notice and Treatment Agreement

All patients will be required to sign a Treatment Agreement as detailed below (which also includes my firm commitment to securely store personal data which has been recorded for treatment, accounting and communication purposes in accordance with General Data Protection Regulations).

Treatment Agreement

Therapy is a cooperative undertaking between a practitioner and a patient (or Patients), the basis of which is agreement on the following points:
I understand the nature of the therapy and it has been explained to my satisfaction.
I understand the probable duration of the therapy or the estimate of the number of therapy sessions required for treatment. This has been explained to my satisfaction.
I have agreed upon a specific outcome for the therapy.
I understand that the guarantee of a successful outcome is not possible and accept that even though the therapist carries out this treatment faultlessly the specific result may not be achieved due to circumstances outside of the therapist's control.
I understand there is a fee for treatment and agree to pay this in the manner agreed before treatment begins.
I have disclosed all information which might affect the outcome of treatment, or of my well being.
I understand the therapist is not responsible for any recurrence of physical or mental problems prior to present treatment.
I give my consent for this treatment by the therapist.
I acknowledge and agree that personal data will be recorded for treatment, accounting and communication purposes and this information is held securely in accordance with General Data Protection Regulations.
I (Lynne Chiswick) agree to discharge my responsibilities with the required standards of ethics and practice and to be bound by the constitution of my professional body. I have made this document available for scrutiny.

I give my consent to this therapy and accept responsibility for current and future conditions both physical and mental.


Signed by Patient ………………………………………… Date……………………………………

-----------------