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: I confirm that I have read, understood and answered all of the previous questions. If there is anything I do not understand, I will ask Rachel. To the best of my knowledge, the information I have given is true and I have not withheld any information concerning my health. I will keep Rachel updated on my health, should there be any changes to the answers given above. I understand that I may experience some minor reactions as my body adjusts to the treatment. I understand that Rachel does not diagnose illness, disease or any other physical or mental condition. I understand that this treatment is not a substitute for medical examination, diagnosis or treatment. Any treatment carried out by Rachel is performed with my agreement and at my own risk. By signing or submitting this form electronically, I understand that I am agreeing to the terms of the disclaimer and to receiving treatment. I also confirm there is no medical reason why I should not receive this treatment.
