Client Form
By signing below, you explicitly give your consent to work with me, and me processing the personal data you have included in this form in accordance with my Privacy Policy that is set out overleaf.

I may from time to time send you details of my services that I feel may interest you, including promotional offers by email or post. You may opt out of receiving such communications at any time. If you would NOT like to receive such offers, please tick below:

Many Thanks

Sarah

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Name *
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Address *
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Email *
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D.O.B *
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Phone number - Home *
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Phone number - Mobile *
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Are You *
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Any Children: *
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Your Doctor: *
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Are you on any medication? If so please give details? *
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Any Main Illness, – Please give details? *
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Have you ever been diagnosed with a psychological issue? If so please give brief details? *
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How many hours sleep on average do you have per night? *
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How much coffee or tea do you drink daily? *
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How much water do you drink daily? *
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Briefly; what is your typical daily food intake? *
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Are you employed, if so what is your employment? *
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Reason for your visit today? *
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How did you hear about Sarah? *
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I hereby give my consent to work with Sarah. Please Sign: *
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Sarah Impey

wwwyour-time-to-shine.com
sarah@your-time-to-shine.com

Tel: 01323 471186
Mob: 07979377092

N.B:

Important: all techniques are used for self development purposes and are in no way intended to replace medical advice or diagnosis. By working with me and using any of the techniques covered, you take full responsibility for your emotional and physical well-being and for anything that may arise whilst using any of the modalities on yourself, either during sessions with me or thereafter on your own.
If you are currently under the instruction of another therapist/doctor/specialist, it is strongly advised to advise them that you are undertaking this therapy.

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