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Your Well-Being Information
PLEASE SUBMIT THIS INFORMATION AT LEAST 48 HOURS PRIOR TO YOUR CONSULTATION. THANK YOU.

This information will inform our work together and enable us to monitor progress. Section 1 is to capture general information. All personal information will be confidential to you, and will not be shared.

By completing this form, you agree that data collected from your progress will help me determine the effectiveness of our time together, and may be used to compare results from others with similar issues.

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DECLARATION OF INFORMED CONSENT
I understand that the BodyTalk session provided by  Certified BodyTalk Practitioner is intended to enhance relaxation, increase communication within areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe and objective. It utilises the body's own innate intelligence to re-establish communication within itself.

I understand that BodyTalk is not a substitute for medical treatments or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the Practitioner prescribe medications.

I understand that participation in a BodyTalk session is voluntary and that at all times I may choose to end my participation.

I agree to pay the amount quoted for the session or session package. Payment is due at time of service. Since time has been especially reserved for me, I understand that a 48 hour cancellation is required to avoid charges for my scheduled session. Cancellations within the full 48 hour period will incur a $40 fee, cancellation within 24 hours requires payment in full and your session will be done remotely via distance.

Packages of 3 sessions are valid for 6 months, packages of 6 are valid for 12 months, packages of 10 are valid for 18 months.

If I have any questions or concerns, I will address these promptly with the BodyTalk Practitioner.

By filling out the form below, you agree to the above.

Date Form Completed
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First Name
Last Name
Date of Birth
MM
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DD
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YYYY
Mobile
Physical address
Describe the reason for your consultation:
How long have you felt this way?
Describe past medical interventions (accidents, surgeries, c-sections, scars):
How is this issue affecting your daily activities?
What are you hoping to achieve with our sessions?
What other health professionals are you seeing? Write N/A if not applicable:
Have you had any medical tests in the last 12 months? Write N/A if not applicable:
What do you do for relaxation?
Do you exercise? What do you do and how often?
Describe your sleep patterns- duration and quality? Do you wake up during the night? If so please write what time you wake, if you stay awake or if you go straight back to sleep?
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