client agreement form

To complete this online form, you will need your health insurance details (if applicable) and your GP details.

1. Confidentiality

Clinical sessions will be treated as confidential. However, there are exceptions to this. There are some circumstances in which confidentiality cannot be maintained and where liaison with relevant services is necessary.

Elucido Psychology Limited is registered with the Information Commissioner’s Office under the Data Protection Act 2018 (Reference ZA533672).

2. Structure of treatment

After assessment of a client’s difficulties, a treatment plan will be proposed. An alternative service might be suggested.

Treatment sessions will typically take place on a weekly basis and are 45-50 minutes. If additional administration work will incur a charge, this will be discussed with the client prior to work being started.

3. Fees and payment

Fees are £120 per session.

Payment is due prior to each session, unless by prior arrangement.

If the client is claiming through a health insurance policy and is required to pay an excess or a contribution to the fees, Elucido Psychology will first invoice the insurer and then invoice the client after deductions have been confirmed. As the client, you agree to pay the excess and/or contributions directly to Elucido Psychology.

Elucido Psychology reserves the right to put on hold or cancel treatment sessions if invoices are not paid. There may be a Late Payment Fee should invoices not be paid on time.

4. Booking appointments

Elucido Psychology operates an online booking calendar. Clients are responsible for requesting appointments for approval. Appointment reminders are sent automatically to the email address supplied by the client.

5. Cancellations

Sessions cancelled with more than 2 working days’ notice will not be charged a fee.

Sessions cancelled with less than 2 working days’ notice, but received and acknowledged by Elucido Psychology more than 24 hours before the appointment time, will be charged a £25 cancellation fee to cover the cost of room hire and administration.

Sessions that are not attended, or when a cancellation is received and acknowledged with less than 24 hours’ notice, the full session fee will be charged to the client.

If a client arrives more than 15 minutes late for a scheduled appointment, there will be insufficient time to proceed with the session and the full session fee will be charged.

As a client funded by health insurance, you will be personally liable to pay any cancellation or non-attendance fees. You will also be personally liable to pay session fees if the insurance policy is not valid at the time of any sessions, or if cover is declined.

7. Ending therapy

Either party may cancel the therapy arrangement at any time without reason or prior notice, subject to the cancellation fees set out in section 5 above and payment of all fees that are due.

If b) please see below. If c) please go to section 9.

If fees will be paid by someone other than the client, Elucido Psychology requires the bill payer’s details and will need their agreement to the terms and conditions in this Therapy Client Agreement:

Please complete this section in full if you are claiming through medical insurance:

I, the client, have read and accept the terms of this Therapy Client Agreement between Elucido Psychology and

Thank you, I look forward to working with you.


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