Please complete this form and click "Submit" at the bottom of the page. There's no need to print the form out, unless you'd like to keep a copy for yourself.Contact informationAll client information is private and confidential.Name* First Middle Last Please write your name as it appears on your birth certificate (incl. middle names)Females - your maiden name (if different from current last name)Address* Street Address Address Line 2 City State Postcode AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Personal DetailsGender*FemaleMaleNon-binaryD.O.B.*Age*Country of birth*Your occupation*Referred byRelationship status:*SingleIn a relationshipDe factoMarriedSeparatedDivorcedWidow(er)Spouse/Partner's name:How long have you been together?Children (name, age, gender):Siblings (name, age, gender):Hobbies/Interests/SportsDo you smoke?*Yes - and I'm comfortable with thatYes - and I'd like to stopNoDo you currently have any active drug, alcohol or other addictions?*Incl. alcohol, gambling etcYesNoDo you experience anxiety, depression or chronic stress levels?* No Yes - Anxiety Yes - Depression Yes - Chronic stress If yes, please indicate which condition.Briefly describe the wellbeing problem(s) you would like to resolve*How long have you had the problem(s)?*Do you regard your wellbeing problem(s) to be:*SevereQuite severeModerateMildDo you have any other chronic or recurring illnesses, diseases or problems?ie. rashes, premenstrual pain, sleeplessness/insomnia, shortness of breath, migraines, constipation, dyspepsia, cystitis, incontinence, infections, coughs, colds, asthma, hypertension, diabetes, arthritis, cancer, heart disease, ulcers, etc...Past accidents or surgeries (incl. date and age):e.g. car accidents, broken bones, falls, sprains, concussions, dental surgery, cesareans, etc.Please list any medication and/or herbal, nutritional supplements you're currently taking.i.e. pharmaceutical medicines (incl birth control), vitamins, supplements, herbal medication, homeopathics or flower essences, etc...Do you have (or suspect) you have any allergies, food sensitivities or intolerances? If yes, please describe.Diet & LifestyleFood preferences* Meat & veg Vegetarian Vegan Macrobiotic High protein Wheat free Gluten free Dairy free Other Briefly explain your daily/weekly intake of sugar, coffee, tea, herbal tea, alcohol:What is your daily water intake?*2+ Litres1 Litre500mlLessAre your bowel movements: Daily Less than daily How often do you exercise? Daily Weekly (2-4x) Occasionally Never On a scale of 1-10 what is your daily energy level?On a scale of 1-10 how would you rate your sleep quality?Select all that relate to your sleeping habits* I'm a night owl I'm a morning person I fall asleep easily I find it difficult to fall asleep I wake up frequently during the night If I wake in the night, I can't get back to sleep I sleep restfully I'm a light sleeper I occasionally experience insomnia I regularly experience insomnia On waking, I feel refreshed On waking, I'm still tired It's hard to get out of bed in the morning On a scale of 1-10 how would you rate your current stress levels?Cause(s) of stress in your life:Do you experience ongoing/occaisional or chronic aches, pains, or headaches/migraines?YesNoIf yes, please explain:Female sectionAre you pregnant?YesNoIf yes, how advanced?Is your menstrual cycle: Regular Irregular Heavy Painful Menopausal (or pre/post) Other Your current health careHave you had Kinesiology before?*YesNoIf yes, please explain how often, purpose of your sessions etc.Do you have a history of trauma and/or abuse?*YesNoHave you been diagnosed with a mental health issue?*YesNoIf yes, please include details of your diagnosis.Are you on a Mental Health Plan*YesNoIf yes, please include details like when you entered the plan & what treatment you're currently receiving. Please also provide the name and contact number of your mental health care practitioner.Are you working with other other health care practitioners?*E.g. Naturopath, Osteopath, Chiropractor, Counselor etcYesNoPersonal Health ConcernsPlease select the issues that relate to you: Alcohol/drug use Anger Anxiety Back and/or neck pain Bullying Career choices Chronic or terminal illness Depression Digestive problems Eating disorders Fears Grieving Guilt Infertility Insomnia Loneliness Marriage/relationship problems Memory Nervousness OCD Overweight PTSD Relaxation Repetitive thoughts Self-sabotage patterns Sleep apnoea Spiritual emergency Stress Terminal diagnosis Tinnitus Underweight Please list any of the above that you would specifically like to deal with:Is there anything else you want me to know?After my session, I would like to feel (3 words):Would you like to sign up to my mailing list?*Yes please!No thank youI newsletters about 1-2 per month. No spamming, I promise!Terms of ServiceBefore submitting your client intake form, please read the Terms of Service below. Privacy All information collected in this form and discussed in your Kinesiology session will remain confidential at all times. The healing process Please be aware that recovering from a chronic, complex illness requires a commitment of time, energy, and resources. Progress can often be cyclical rather than linear. You may experience periods throughout your treatment where your improvement plateaus. This is normal. It is important to continue treatment through these cycles to achieve a successful outcome. Other possible costs in addition to your session: Liquid Crystals and/or nutritional supplements I'm also a Liquid Crystals practitioner, and will often prescribe a Liquid Crystals remedy to support your Kinesiology session. Remedies are either $7.50-$15 for a Single crystal or $21-$35 for a Trinity. Postage and handling (if required) is $10. If your body tests up as needing nutritional supplement support, I do keep some stock on hand, and/or I can order supplements on your behalf. Supplement prices vary. It's always your choice as to whether or not you'd like a recommended Liquid Crystals remedy or nutritional supplement. Cancellation/No-Show Policy I require 24 hours notice should you elect to cancel or reschedule an appointment. If you fail to attend a scheduled appointment without notice then the full cost of the session will be charged. Repeated last-minute reschedules If you find yourself in a pattern of rescheduling, even when providing 24 hours notice, this will also be considered a cancellation/no-show and the full cost of the session will be charged. Agreement to Terms of Service By filling out the required information, you agree that you have read and accept the above terms of service.Agreement* I agree to the above Terms of Service This iframe contains the logic required to handle Ajax powered Gravity Forms.
