To place an order with Genius Within, please complete the form below. Company details Company Name (required for employees/if applicable) Client Title (Mr/Mrs/Ms/Miss/DR) (required) MrMrsMsMissDr Client Name (required) Best contact number home/work/mobile (required) Email address (required) Work address (required for employees) Line manager name (required for employees) Line manager email address (required for employees) Line manager contact number (required for employees) Order Details Please tick the service(s) you wish to purchase and enter the amount of sessions required (e.g. 6x2 hours, recommended, one session per focus area plus a summary session at the end of the programme) If the service you want is not listed please enter below or give us a call. Strategy coaching 2 hours Strategy coaching 3 hours Co-coaching (3 hours) Manager Coaching (3 hours) Awareness Training Cognitive/diagnostic assessment Positive Assessment Workplace needs assessment Cascade Training Inside Out Training Extra notes on service(s) required Finance Details Purchase order number (if applicable) Finance contact name (if applicable) Finance contact number (if applicable) Finance email address (if applicable) Invoicing department address (if applicable) Additional Info Reason for referral (E.g have you received any previous support? What condition/neurodiversity are you requiring support for?) (required) Was this referral recommended by Access To Work? If yes, please state your funding allowance. YesNo Is there car parking available? (if applicable) YesNo Client working hours? (if applicable) How we use the Personal Data that you provide to us All personal information you give to us, including sensitive personal information about your neurodiverse condition, will be processed in accordance with current data protection legislation. Genius Within CIC is the data controller of the personal information you provide If you have any questions about how your personal information is processed, or you wish to request a copy of, delete or amend the personal information that you have provided to us, please contact our Data Protection Officer on 01273 890502 or email email@example.com The following information is to assist you using this service: Genius Within CIC processes personal information for the purposes of providing strategy coaching. The legal basis for processing personal data is to ensure compliance with the contract to provide strategy coaching for neurodiverse conditions. Access is limited to authorised users only. Authorised users are Genius Within CIC Client Service Staff, the coach and EKO UK Ltd. EKO UK Ltd are granted access for the purpose of maintenance and back up of the database. Data is protected from unauthorised access. Personal information is retained and stored securely. All assessments are stored indefinitely in line with BPS guidelines. Data is held in secure computer files, which have restricted access. By continuing with your request for the provision of services, you hereby consent to the processing of your information as set out in this order form. You may withdraw your consent at any time by contacting us on 01273 890502 or by emailing firstname.lastname@example.org Print name (required) Date (required) I confirm that I have read and agree to the terms and conditions of Genius Within 2016.