Please complete the registration form below, to let us help you in the best way.

The terms and conditions can be downloaded here

Terms and Conditions for Studying at FfL

Terms and Conditions for Speech or Language Therapy at FfL

Terms and Conditions for Psychological Treatment at FfL

Terms and Conditions for ABA therapy at FfL

I agree with the terms and conditions*

Yes

Adult Last Name*

Adult First Name*

Adult Nationality*

Adult Date of Birth*

Adult Gender*

Female

Male

Adult Email

Adult phone:

Area Code

-

Phone Number

Address for Invoice*

Invoice Street AddressInvoice CityInvoice Post CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweInvoice Country

Do you live at the address above:*

yes

no

Home Address:*

Adult Street AddressAdult CityAdult Postal Code

We would like to know your employer's name for our statistical purposes.  We sometimes contact companies to ask for funding and it helps us to be able to show how often our services have been used.  We NEVER share names of clients or personal data and all your information is treated with complete confidentiality. 

Adult Employer's company

Name of Practitioners that you will use, if known:

Sylvia Leck

Paul Decker

Amanda Preussler

April Remfrey

David Owen

other

Please tell us how you found us:

Confidential notes you may wish to note now to help us:

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