Client Details & Consent Form

Name*

First NameLast Name

Date of birth

Date

Blood Type (if known)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone*

How did you hear about my services?

Name of Emergency Contact*

First NameLast Name

Relationship to client*

Phone*

Q 1: I give my consent for Kinesiology treatment, and understand my session is confidential. I understand that I may need to give myself time to process the information covered during my session, due to changes in energy. (This is absolutely normal and part of the healing process)*

YesNo

Q2: Have you been diagnosed with Mental Health Issues? If Yes - please complete section below - otherwise go to Q3*

YesNo

Please note if you have been diagnosed with a Mental Health issue, it is important to let your kinesiologist know and to provide contact details for your mental health provider.

Note that your kinesiologist may contact your mental health professional in the case where they are concerned for your wellbeing.

2(a): I give permission for my kinesiology practitioner to correspond with my Mental Health practitioner ifwhen the need arises

YesNo

2(b): Mental Health Professional Details:      First Name   Last Name
Phone:      Phone Number
Address: Street Address     City   State   Postcode

3: I give permission for my practitioner to pass information to other health professionals if necessary(e.g. medical doctor, chiropractor). (I understand that my kinesiologist will ALWAYS discuss this prior to contacting or providing my information to other health professionals*

YesNo

4: I give permission for Well of Harmony to contact me for advertising and promotional purposes.(I understand that I may withdraw this permission at any time via e-mail, and that my details will never be shared with 3rd parties)*

YesNo

Newsletter

Yes, subscribe me to Well of Harmony's newsletter. I give permission for Well of Harmony to contact me for advertising and promotional purposes. (I understand that I may withdraw this permission at any time via e-mail, and that my details will never be shared with 3rd parties).

Please list any relevant health concerns

Why is your health important to you?

Do you think that the signs and symptoms that you are experiencing are trying to tell you something?

What do you feel is stopping you from achieving your full health potential?

What areas of your life would you like to improve first?

Please list any medicationsupplements and dosage

Please list any other health professionals that you are seeing

Clinic Policies: Refund Policy: Due to the nature of therapies, there are no refunds on any therapy given.

Cancellation Policy: In fairness to all our valued clients, if you fail to attend your appointment or give less than 24 hours notice of cancellation you will incur a cancellation charge of 100% of the full consultation cost.

Informed consent waiver: I engage voluntarily in consultations, workshops and programs at Well Of Harmony. I understand that these consultations, workshops and programs do not provide a substitute for professional medical health care advice and consultation.

I understand that if am taking any medications or have any health concerns that I should disclose this with my practitioner and seek further medical advice where needed. I also acknowledge that I am responsible for monitoring my own conditions and should any unusual symptoms occur, I will inform my practitioner and seek medical advice from my doctor.

In signing this consent form, l affirm that have read this form in its entirety and that I understand the nature of my consultation, workshop and programs at Well Of Harmony. I agree to assume anyall risks of the therapies that I am undertaking, and under reasonable expectations agree to hold harmless Well Of Harmony, Sinead Kelly and any contracting therapists conducting the therapies am participating in, from any claims, suits, losses or related causes of action for damages including, but not limited to such claims that may result from my injury or death, accidental or otherwise.

I am 18 years of age or over and the details thatl have provided are true and correct. I agree to the informed consent waiver outlined above.

Print Full Name

Signature*

Client Details

Emergency Contact Details

Consent

Health Concerns

Clinic Policies