Safer Space Holistic- Consultation Form
I ask the following questions to create a holistic understanding of the person, as I recognise that your life experiences can affect your health and wellbeing. With an awareness of your experiences, I hope to be able to provide a more effective and enjoyable treatment.
It’s also important for you to know that any information you provide is completely confidential, will be protected as required by law, and will be recieved with complete non-judgement.
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Your Name *
Your Pronouns (e.g. she/her, they/them, he/him)
Date of Birth *
Email *
Your Contact Number (in case of short-notice changes ) *
Emergency Contact Name & Number (if you don't want to name an emergency contact, you can just leave this blank)
Postal Area (e.g. BS16, BS4, SE13...) *
Do you identify with any of the following groups? If you would like to share any further details you can use 'Other'.
If you selected 'people with disabilities' - Do you have any accessibility requirements?
If you selected 'survivor of trauma', please fill in this additional form before your first session:
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The following conditions may directly affect your treatment. Please indicate if any of the following apply to you and provide details in the 'Other' section if relevant.
Do you have any other medical conditions or history that you believe could affect your treatment and that you wish to disclose? This is particularly helpful for me to know if it has informed your search for a treatment with Safer Space Holistic (e.g. a disability, mental health conditions)
Do you have any restrictions in movement or movements that you think may be harmful?
I like to let you choose the music and any fragrances (e.g. in lotions and balms) we will use in the session. However please indicate here if you would prefer no music, fragrances or oils to be used at all.
Would you like to bring somebody with you to your first appointment?
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I will email you in response to your form submission. Would you also like to speak on the phone before your first appointment?
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When would you be available for a treatment?
Preferred location?
Is there anything else you'd like me to know?
Where did you hear about me? (E.g. Google, Instagram) If recommended to me by someone, please give their name :) 
Consent and Policy Agreement: “I agree and understand that bodywork is intended for relaxation, and that it is not meant to diagnose, treat or  remedy any illness, disease, injury, physical condition or mental disorder. I agree and understand that sessions in external premises cancelled between  0 - 3 days may incur a fee. I agree and understand that bodywork is strictly non-sexual. Under extenuating circumstances, either party reserves the right to immediately terminate the session.” Do you agree to the above statements? *
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