Client form

Completing this client form when you have booked your appointment with me enables me to learn about the issue you are facing prior to our session. This will allow us to have a richer consultation during your session.

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Your message has been sent

Thank you for completing the client form. I look forward to our session together.

Full name

Phone Number

Address

Date of birth

Marital status

Occupation

Religion/Spirituality

Next of Kin

Phone Number

What is the issue/ problem you want to focus on?

What is your evaluation of this issue/problem on a ratio of 1-10? (10 = serious)

Have you had this issue/ problem before?

Have you had any serious stressors/ traumas/ accidents/ illnesses and if so, what were they?

Have you had any other health care treatment for this issue/problem and if so, what was it?

Do you drink adequate water?

Do you have a healthy balanced diet?

Do you exercise regularly?

Do you sleep well consistently?

Are you currently on any medications/ supplements/ homeopathic remedies? If yes, please specify.

Do you have any allergies?

Client consent: I consent to kinesiology sessions with the understanding that I will not receive diagnoses and that the session will be conducted using a model of self-responsibility where I will be involved in the processes and techniques used. I accept that the sessions will have a holistic approach and will not focus only on symptoms. Y/N

Any additional comments

How did you hear about me?

Bookings/Cancellation policy

You will be sent a text message reminder 48 hours prior to your appointment time.

Changes and cancellations within 24 hours may incur full payment of consultation fees. You can change your appointment anytime from booking to 24 hours prior to your appointment. If your cancellation falls within 24 hrs, you may be responsible for the payment of your session. This is with respect and consideration for others who may have requested your appointment time.

Payment terms

In person session: Bank transfer or cash on day of session

Online session: Bank transfer on day of session