Full Name:
Session Date:
Email:
Telephone No:
Mobile No:
DOB:
Current Address:
Postcode:
Occupation:
Referred By:
Current symptoms (emotional, physical, mental, spiritual), and why you have come for this healing session:
Body health history (e.g. illness, accidents, operations, asthma, epilepsy, allergies, diabetes?). Are you taking any medication? If so, please give details. If you recently (within the last 3 months) stopped taking any medication, please also give details:
Family background (relationship with mother, father, siblings):
Birth and prenatal information, if known (easy birth, caesarean, premature, forceps, mother on drugs? Were you wanted? Breast fed? How was your mother during the pregnancy?)
Patterns/fears/recurring issues in your life?
Sexuality flowing or blocked (now of in the past). Sexual issues? Relationship issues?
Menstrual cycle (if applicable) – regular, irregular, PMS, menopausal? Any pain or symptoms?
Psychiatric history (mental health problems and referrals, depression, medication, self harm). Have you ever felt suicidal now or in the past? Have you ever had a psychotic episode or been sectioned under the Mental Health Act?
Problematic habits (now or in the past)? (smoking, coffee, sugar, alcohol, drugs, phone, shopping etc)
Major life traumas?
Have you tried any other therapies or treatments?
What gives you comfort, support, joy or pleasure in life?
Do you have any spiritual or religious beliefs?
Name and phone numbers of someone I can contact in an emergency. Please also give your doctor’s name and number.
Disclaimer: By booking your appointment and making payment you acknowledge that you are doing so of your own free will and have not been coerced to participate by Rachel Mitton or her associates to undergo or partake in any particular treatment. You freely acknowledge that any energy healing treatment received is done with your full awareness and acknowledgement that it is of your own free will. You also acknowledge that you have provided full details by completing this form as required and any symptoms or illnesses you have are ultimately your responsibility to heal and that there are many causes of ill health. You understand that Rachel will deliver treatments to the best of her ability but cannot be held responsible for any deterioration or inability to heal.
