REGFORM 1A

Registration Form for North West UK Listings

Please fill in your details and SUBMIT THE FORM BELOW for a LISTING in our online
THERAPISTS DIRECTORY

If you haven't already done so, please first read our Terms & Conditions

We also recommend that you *Click Here for some useful advice, before you fill in the form.
(eg. How soon you will see your listing on the website, what you should include in your profile,
how listings are positioned in the Therapists Directory, how to update your listing, and other FAQs.)

 * (Page opens in a separate window, so you can refer to it whilst completing the form, without losing any of your entered details.)

Please Note: If you already have a listing in our Therapists Directory,
and need to update it, please don't use this form. Instead go to the Therapists Update Form
* Required Fields

WHEN FILLING IN THE FORM... Please enter your details using both Upper and Lower case text, as applicable, for normal readability.
(ie. Don't use all Capital Letters, or all lower case letters.)


* Your own Practice or Business Name
If you don't have a separate practice name,
give the name you normally work under as a Therapist.
(This is what you will see in the top heading of your listing)
  * Who is the listing for?
(Select one only)		 Individual Practitioner
Clinic or Group Practice
* Practitioner's First name

* Practitioner's Last Name




(For Clinic or Group Practice entries, we add the word 'Various' on the 'Practitioner' line of your listing - but please also give a Contact Name here to include in the listing. This should be the Practice Manager/ Owner, or whoever normally deals with enquiries from clients etc.

* Landline Phone No.
 If you don't use a landline number, or would prefer not to display it on the website, please just enter '000' here.
Mobile Phone No.
* Email Address
 The one you normally use for business enquiries
Website Address: http://
In which town(s) do you mainly practise?
This can include places you visit clients in,
if you offer a mobile or on-site service.
*Please select the County/Area
you're based in, or mainly work from
(1 only)
Cumbria Cheshire Wirral
North Wales Lancashire Merseyside
  Gtr Manchester  
 
On which Therapy pages would you
like your listing to be displayed on?
(You can select up to five)
Help Tip: When you've finished selecting your therapies, remember to click the mouse away from the drop-down list first, before you scroll down the page to the next question. Otherwise you may accidentally select the wrong therapy.
1   4
2   5
3    
Do you offer Home/Workplace visits? Yes     No
*Are you insured to practice? Yes     No

*Qualifications / Memberships
These should be included in all practitioner entries and should relate to the Therapies you're currently offering.

If the details are for a group practice, you can either
include the most relevant qualifications from each therapist, or you can put down
'All Therapists are individually qualified'. (or similar)
Abbreviated Full Version
Any others?
  *Please note:
We don't require proof of qualifications, insurance etc., however, we do state on the website that any therapist/ practitioner listed is happy to show evidence of these to clients if asked.
If you would like your practice address shown in your listing, or the address of a clinic or therapy centre you work from, please enter the name and full address of the practice (inc.postcode) Name of Practice

Address of Practice (inc. postcode)
Address:
Town:
County:
Postcode:

About Your Practice
 Briefly describe anything about yourself or your practice that you would like to tell potential clients. e.g, the way you approach your work, experience, specific health problems you specialise in, any additional or unusual therapies you offer, etc.

No more than 150 words please!
 (Over-long profiles will be edited at our discretion)
 Nearly finished!

Please be aware that all the details you have given above, will be used to prepare your listing in our Therapists Directory, and will be available for public viewing on the Internet. If there's anything above you're not happy to display on our web pages, then please don't include it.

Please tick this box to say you have read and understood our Terms & Conditions

Finally, please complete the details below - FOR OUR RECORDS ONLY
(Information in this section will not be displayed on the website)
Title     Other 

Please give your full address
(if different from your Practice Address)


If you didn't give a Landline phone number above,
please include that here also, if applicable)

This information will be kept private and not displayed on the website unless you have also given it above for public use. We will only use this to get in touch with you in connection with your listing, if we're unable to reach you by email. We never pass on or sell your private details to any third parties for marketing purposes.
Solution Graphics

Address:
Town:
County:
Postcode:
Phone:

HOW TO PAY FOR YOUR LISTING:
The fee for advertising in our Therapists Directory is £20. We only ask you to pay for one year at a time.
(This is for the first year only - when you renew in a year's time, the fee will be £18 for the following year.)

You can pay now securely online using any Credit/Debit Card, or your PayPal account if you have one, or, if you prefer, you can send us a cheque in the post. (It isn't necessary to have a PayPal account to use the online payment option)

Please choose how you wish to pay...

 I will be paying online
I would prefer to send a cheque

Please check all the details you have entered, and make sure you have selected the correct payment option above. If you're happy with everything, just click the 'Submit' button below, and you'll be able to complete the payment process.

We'll prepare your listing for you, and your details should be on the website within 3 working days of us receiving your payment. We'll email you to let you know when it's online, and we'll include a receipt if you pay by cheque. (If you pay online, you'll automatically get a receipt from PayPal to confirm your transaction).

Important Note: If you don't appear to receive any Emails from us... please also check your Bulk, Spam or Junk Mail folder as well as your usual Inbox, in case they have mistakenly been diverted to there.
Tell us - How did you find out about this website?  
To prevent misuse of this form, please enter in the box the missing letter...
A B ? D E F G H I J K L M N O
Finally, click here to send us your details.   
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