Confidentiality: Please note that all information will be kept strictly confidential except in the cases that we are legally obliged to report, such as a threat of injury to yourself or others.
Date of Birth:
Emergency Contact Name and Number:
*List your challenges in order of priority: (e.g. psychological, emotional, blocks, repeating patterns, physical, financial, fears, phobias, addictions)
*Which goals would you like to achieve?
Do you have any potentially life threatening conditions? (e.g. heart trouble)
Lifestyle and history (including work and exercise):
Are there any genetic or inherited aspects or patterns to the issue? (included in parents, siblings, relatives)
Medications and supplements you are taking: (Include supplements, vitamins and prescribed drugs and dosages. If you were on long term medication in the past, please include it here)
Medical History: (Including operations and medical diagnosis)
What is your weekly alcohol intake? (in units)
What is your daily intake of water?
Is a doctor currently treating you? (Yes/No)
Please confirm yes or no that you agree to our Terms and Conditions and note that appointment cancellations with less than 48 hours notice incur the full service fee:
How did you hear about us?