This Client Form is for One-to-One Consultations. Prior to your first Personal Consultation, please complete this form as much as possible, providing information on your challenges and which goals and outcomes you would like to achieve. The more that you can tell me about yourself, the more I am able to support you. Signing this document confirms that agree to our Terms and Conditions. Please note that appointment cancellations with less than 48 hours’ notice incur the full service fee. Please return this form prior to your session to firstname.lastname@example.org.
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:
Full Address including Post Code/Zip:
*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?
Lifestyle and history (including work and exercise):
Are there any genetic or inherited aspects or patterns to the issue? (included in parents, siblings, relatives):
Do you have any potentially life threatening conditions? (e.g. heart trouble)
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) and is a doctor currently treating you? (Yes/No):
What is your weekly alcohol intake? (in units)
What is your daily intake of water?
How did you hear about us?