New client form | Return to Source Wellbeing - Kinesiology & Intuitive Healing

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 information
All 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 Country
Phone*
Email*
Personal Details
Gender*
- Female
- Male
- Non-binary
D.O.B.*
Age*
Country of birth*
Your occupation*
Referred by
Relationship status:*
- Single
- In a relationship
- De facto
- Married
- Separated
- Divorced
- Widow(er)
Spouse/Partner's name:
How long have you been together?
Children (name, age, gender):
Siblings (name, age, gender):
Hobbies/Interests/Sports
Do you smoke?*
- Yes - and I'm comfortable with that
- Yes - and I'd like to stop
- No
Do you currently have any active drug, alcohol or other addictions?*
Incl. alcohol, gambling etc
- Yes
- No
Do 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:*
- Severe
- Quite severe
- Moderate
- Mild
Do 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 & Lifestyle
Food 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+ Litres
- 1 Litre
- 500ml
- Less
Are 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?
- Yes
- No
If yes, please explain:
Female section
Are you pregnant?
- Yes
- No
If yes, how advanced?
Is your menstrual cycle:
- Regular
- Irregular
- Heavy
- Painful
- Menopausal (or pre/post)
- Other
Your current health care
Have you had Kinesiology before?*
- Yes
- No
If yes, please explain how often, purpose of your sessions etc.
Do you have a history of trauma and/or abuse?*
- Yes
- No
Have you been diagnosed with a mental health issue?*
- Yes
- No
If yes, please include details of your diagnosis.
Are you on a Mental Health Plan*
- Yes
- No
If 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 etc
- Yes
- No
Personal Health Concerns
Please 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 you
I newsletters about 1-2 per month. No spamming, I promise!
Terms of Service
Before 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

Contact information

Personal Details

Diet & Lifestyle

Female section

Your current health care

Personal Health Concerns

Terms of Service