Nutrition Consultation Volunteer Registration Form
Thank you for your interest in the CNELM Nutritional Therapy Teaching Clinic.  We would like to add you to the register of volunteers for student consultations. To ensure we allocate you to the appropriate student please provide us with the information requested on this form.

The Nutritional Therapy Teaching Clinic provides an initial consultation, lasting about 2 hours, a researched plan sent to you based on your consultation, a 15 min coaching call to answer any queries and a follow on consultation of about an hour. This is over  a 6-8 week time frame. You will be asked to fill in a questionnaire before the first consultation, which is kept safe and confidential within our Data Protection Policy. The questionnaire and terms of agreement should take approximately 1-2 hours to complete.

Following completion of this Volunteer Registration Form you will be contacted by a student to begin the process of booking a consultation. Due to timings of study programmes, it may take several weeks for contact to be made. You will receive a copy of this completed form by email to confirm that we have received your details. If in the meantime you have any queries then please contact the Clinic Manager: janet.lakin@cnelm.ac.uk

Students rely on seeing clients in order to complete their education with us. We appreciate your commitment to the process and look forward to welcoming you to the Teaching Clinic.

Please provide us with a personal email address. Due to the sensitivity of the information provided to you it is our policy to only communicate via your personal email.
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Email *
DATA PROTECTION CONSENT *
Data Protection Statement: Under both the UK's Data Protection Act 2018 and UK GDPR we are required to gain your explicit consent to collect, process and store your Personal Data. Your consent cannot be assumed simply by completing this Form. Therefore, please answer the Data Protection Question to confirm your consent.

The legal reason for collection, processing and storing your Data in based upon your Consent and Contractual Obligations as we will use your Data to provide you with services. If you engage in a Nutritional Therapy Consultation then a more detailed Data Protection Agreement will be entered into outlining additional Legal Reasons for collecting, processing, storing and retaining your Data.

Please Confirm your Consent for CNELM to collect and process your Data for the express purpose of administrating your request to volunteer in the CNELM Nutritional Therapy (and Dietary Education) Training Clinic. This includes assessment of eligibility, allocation of a matched Student and Clinic Supervisor to offer you a Dietary Educator Consultation or a Nutritional Therapy Consultation or both.  CNELM will annually contact volunteers to confirm your continued wish to remain on the volunteer list. Without your explicit Consent your application cannot proceed or be processed. Tick as applicable.
Required
Title
First Name *
Surname *
Email address *
Telephone Number *
I confirm that I give permission for the student to write to my medical practitioner. I will provide, prior to the consultation, details of my medical practitioner on the health questionnaire. (Consultations are not able to proceed if these details are not given. The health questionnaire will be sent once the consultation has been booked.) *
Within the Teaching Clinic, we ask for these details to be provided, to ensure client safety and as a duty of care. 
Do you have a diagnosed health condition? *
If so, please provide brief detail of the condition:
Are you currently taking any prescribed medications? *
If so, please provide further details:
Please use this space to let us know if you need us to consider any special circumstances or need for support. For example: wheelchair access, difficulties using stairs, impaired eyesight, dyslexia etc.  
Currently, all student nutrition consultations are held online using meeting software. Therefore you will need access to a computer and Wifi and for the consultation to take place in a space that is private.
How did you hear of the CNELM Student clinic?  (If through a student please give us the full student name) *
It is our Policy that students do not work with family members, close friends and work colleagues. If you were recommended to the clinic by one of our students please provide the name of the student. We can then ensure you are allocated to another student.  
Are you a family member of any member of CNELM staff? *
If ‘yes’ please name the member of staff.
If you reside outside of the UK please let us know your time zone. (Please note that the Teaching Clinic operates in UK time zone during the working day and Saturdays.)
Preferred consultation times (delete as appropriate)
The CNELM Teaching Clinic is an online nutritional therapy clinic and as such it is assumed that clients have the necessary technological skills and access to equipment to complete required documents and to fully engage with the process. If you do not have the necessary skills and equipment then you can nominate a trusted third party to help with the process.

I nominate a trusted third party to access and help me complete my online document: *
Required
If YES please give their name and email address:
In exceptional circumstances it can be facilitated to be sent documents related to the consultation by post. A charge will be applied if documents are to be posted. If you wish to have more details on this then please contact the clinic manager: janet.lakin@cnelm.ac.uk.

I will require printed documents:
 *
Please fill in your initials. *
You will be added to a register of volunteers and you can expect to be contacted by a supervisor or student in the near future. Please be assured that your personal data will remain confidential and will be stored in electronic form with restricted access in Google Drive. Full details on how we handle your data is given in the Teaching Clinic Terms of Agreement which will be sent to you when you book the consultation. If you wish to access the Terms of Agreement prior to this then please contact Emma Stiles at the email below.  All student consultations are supervised by a fully qualified nutritional therapist who is a member of the professional body BANT (British Association for Nutrition and Lifestyle Medicine) and is registered with the CNHC (Complementary and Natural Health Care Council) voluntary register.  Our supervisors are committed to providing quality of care for our clients. The initial consultation usually lasts two hours although this will be confirmed at the time of booking. You will then receive a short coaching call to support your nutrition and lifestyle plan. About 8 weeks later you will be required to attend a follow-up session. The follow-up session is one hour long. Prior to the initial consultation you will be asked to complete a health questionnaire and return it around 10 days before so that the student/s can prepare.  The consultations are free of charge. You may be recommended laboratory testing or food supplements which you would need to pay for yourself but these are not obligatory and entirely optional.  Thank you for your interest in participating in our student clinic helping our students to achieve a high level of clinical competency to support their future practice.  
A copy of your responses will be emailed to the address you provided.
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