Take Time Client Form 1819

Welcome to the Take Time on-line self-referral form.

All information on this form is confidential to Take Time. This questionnaire is located on a secure server and is encrypted. The Web address begins with https and has a small padlock icon showing you that the connection is secure. Any answers that you provide on this questionnaire will also be encrypted.

Please complete this form if you'd like to attend Take Time for an appointment.

Data Protection: We ask permission to keep confidential case records in conformity with the Data Protection Act 1998. These notes are kept securely and are only accessible to Take Time staff except in exceptional circumstances which require a breach of confidentiality, that is when a staff member believes you will cause serious physical harm to others or yourself. Even in this instance, the staff member will endeavour to discuss with you first the need to break confidentiality.

If you submit your answers you will not be able to return to this page.