Hayley Benseman client consultation form
Microfascial Unwinding | Myofascial Release | Intuitive Healings | Scar Release
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Email *
Name *
First and last name
Gender *
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Which treatment are you interested in *
Required
Address *
Phone number *
Date of birth *
How did you hear about this service
List any medications, supplements, or herbal remedies you currently take:
Please list known allergies or sensitivities – incl allergies to plants / plant oils:
Are you pregnant
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If so how many weeks are you?
What are your specific concerns currently? *
What daily activities are you finding difficult or are limited because of your above concerns?
Please list any or ALL Injuries or surgeries and approximate dates (scars are important to mention) :
What does your alcohol consumption look like? *
Required
What does your caffeine consumption look like (incl coffee / energy drinks) *
What is your stress level right now? *
Required
How much time do you have for yourself to relax and self care i.e. hobbies, meditation, grounding etc
Do/can you exercise currently? And if so, what kind and how often?
How many hours a night do you sleep? Is it restful? Do you wake up refreshed or lethargic?
How is your mental & emotional health now? Are there any events current or old that are linked to these emotions – feelings that you would like me to know before we talk?
What is your goal for this session? *
By SUBMITTING THIS FORM, you agree to the following: 1) I give my permission to receive services provided by Hayley Benseman. 2) I understand that this therapy is not a substitute for traditional medical treatment or medications. 3) I understand that Hayley Benseman does not diagnose illnesses or injuries or prescribe medications. 4) I have clearance from my physician to receive this therapy.  5) I understand the importance of informing Hayley Benseman of all medical conditions and medications I am taking, and to let Hayley Benseman know about any changes to these. I understand that there may be additional risks based on my physical condition. 6) I understand that it is my responsibility to inform Hayley Benseman of any discomfort I may feel during the session so she may adjust accordingly. 7) I understand that I or Hayley Benseman may terminate the session at any time. 8) I have been given a chance to ask questions about the session and my questions have been answered.  9) Privacy and Confidentiality Disclaimer

I understand that all personal information and notes taken during my session are confidential and will be securely stored. This information will only be used to provide the best possible care and will not be shared with third parties without my explicit consent, except as required by law.

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A copy of your responses will be emailed to the address you provided.
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