Client Form

Please complete and return this client form prior to your first session*.

 

First Name:

 


Last Name:

 


Email:

 


Skype ID:

 


Address 1:

 


Address 2:

 


City:

 


Zip/Post Code:

 


Country:

 


Date of Birth:

 


Tel:

 


Emergency Contact:

 


Today’s Date:

 


How did you hear about us?:

 



List Your Challenges in Order of Priority: (e.g. physical, emotional, mental, financial, fears, phobias, addictions)

 













Do you have any potentially life threatening conditions?: (e.g. heart trouble)

 





Lifestyle and history:

 













Are there any genetic or inherited aspects or patterns to the issue? (included in relatives, ancestors, siblings, past lives that you are aware of)

 













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)

 


Doctor’s Name and Address:

 




Terms and Conditions: (please confirm yes or no that you agree to our terms and conditions here and note that appointment cancellations with less than 24 hours notice incur the full service fee)

 


 

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. Please answer all questions as the more that you can tell us about yourself, the more we are able to support you.

Return Form

*Please print, complete and return this client form prior to your first session to hello@mariaspiteri.com.