The
Application Form
For E-mail Counselling, Support and Therapy
If you wish to have e-mail
counselling / therapy
from Dr. Michael G Millett at Elevated Therapy International. Complete
ALL
of the confidential form
below
and press the submit button at the foot of the page to send the
information. Michael will study your information carefully and will indicate
whether he might be able to help you by aiming to reply to you within 24-48
hours with a general response email to tell you if he thinks this
service might help you.
You can then arrange to make payment for three emails in advance
here through the Elevated Shoppe. Michael will tell you how to do this. Do NOT make
payment until you hear from him.
Just EFT and E-mail Support please!
If you are requesting the FREE EFT Manual and
three support sessions applicable to this, please complete, name,
address,
e-mail fields and towards the bottom of the page where it says "Any further comments or information you would like to make or add?" - just write in EFT Support and lastly `check`
the agreement statement above that.
Your name or alias:
Double-Check this E-mail
address:
No. and Street:
City or Town:
Zip or Postal Code:
Country:
What is your Gender?
Male
Female
Briefly describe your family and work situation. Are
you married / re-married/ single/ divorced/ widowed? For how long? With or
without children? Other dependent relatives?
In work? Write Below
Describe your problem or issue. What do you fear most about
your present
situation? Write Below
What are you expecting to gain from counselling/therapy with
Dr. Millett?
Write Below
What have you done about your problem or issue so far? Write Below
Are you
an active member of an established church or religion?
Yes
No
Are you receiving counselling from any other source?
Yes
No
Are you taking any prescribed medication?
Yes
No
"I have read and understood Elevated
Therapy International`s
Counselling On-Line's Confidentiality Policy printed at the foot of the
page, and I accept it. I understand that I am in charge and accountable
of my response to any counselling / therapy and advice I may receive,
and
that this counselling / therapy and advice given does not create any
legal
liability on behalf of Elevated Therapy, or on behalf of Dr. Michael G
Millett."
I agree with the
statement
above and accept the conditions described in it.
I disagree with
the statement above and do NOT accept the conditions described
in
it.
Agree
Disagree
Any further comments or information you would like to make or
add? Write Below
Confidentiality
Policy
Dr. Millett is happy
to
promise that he will keep confidential anything that clients reveal to
him. As a psychotherapist, he has an obligation to keep communications
confidential. However, it is generally recognised that there is a limit
to this confidentiality: He may be obliged to breach confidentiality if
you reveal anything indicating that you are involved in
harming yourself or
someone
else – especially a child – so that the appropriate authorities can
be
informed.
This is a standard
ethical
code.
Welcome to Counselling / Therapy by
E-mail at
Elevated Therapy International and Dr. Millett will look forward to
getting
back to you shortly.
Secure On-Line Purchase at Elevated Therapy International: This means that your personal payment information is encrypted when you buy at the Elevated Shoppe and secured through SECPay This prevents unauthorized people from seeing the information that is sent to or from The Elevated Therapy International Shoppe. It is deemed a "secure" site.
ORDERS SENT TO MOST DESTINATIONS WORLDWIDE AND ALL MAJOR CREDIT AND DEBIT CARDS ARE ACCEPTED SECURE ON-LINE THROUGH SECPay.
Just so you're aware - THIS IS A RIGHT TO PRIVACY SITE! which means that YOUR PRIVACY & CONFIDENTIALITY ARE GUARANTEED!
