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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Personal DetailsD.O.B.*Age*Country of birth*Your occupation*Referred byRelationship status:*SingleIn a relationshipDe factoMarriedSeparatedDivorcedWidow(er)Spouse/Partner's name:Children (name, age, gender):Siblings (name, age, gender):Hobbies/Interests/SportsDo you smoke?*YesNoDo you experience anxiety, depression or chronic stress levels?*YesNoBriefly 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 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 supplementsi.e. pharmaceutical medicines (incl birth control), vitamins, supplements, herbal medication, homeopathics or flower essences, etc...Do you have any allergies? If YES, please state.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?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 Personal Health ConcernsPlease tick any of the following issues which relate to you: Alcohol/drug use Anger Anxiety Back and/or neck pain Career choices Chronic or terminal illness Depression Digestive problems Fears Grieving Guilt Infertility Insomnia Loneliness Marriage/relationship problems Memory Nervousness PTSD Relaxation Repetitive thoughts Self-sabotage patterns Sleep Apnoea Spiritual emergency Stress Trauma Tinnitus 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.
