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:
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?
Have you tried any other therapies or treatments?
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.
