Let’s Get Started

I’m looking forward to working with you.

Please review and confirm ourSupervision Agreementand complete the form below so we can get started.

Personal Information

First name

Last name

Email address

Date of birth

Phone number

Home address

Town / City

County

Postcode

Is this the address where you will usually be for our supervision sessions?

Emergency Contact

Name

Contact number

Practice Details

Practice name

Practice address

Website

Membership body

Membership body register number

I am currently insured for my therapy practice and I renew my insurance regularly.

Please email a copy of your qualification certificate (or your 'fitness to practice' letter if you are currently a student) to: helen@themenopausetherapist.com.

GP Details

Name

Contact number

Surgery name & address

How did you hear about The Menopause Therapist?

I have read and agree to the terms of ourSupervision Agreement.