In order to assist us with the consultation process, all clients are required to complete the below form.
If you have any questions while completing this form, please contact Colleen.

This information provided by you will be treated as strictly confidential.
Answer only the questions that you feel comfortable to share.

Health Evaluation Form (intake form 10/24)

Patient details

Medical details

0 = minimal stress 10 = extreme stress

Consent

I consent to these sessions with the understanding that they are not designed to diagnose or prescribe. 

I accept that the session will be conducted using a model of self-responsibility and that the sessions are a holistic approach,  not focusing only on symptoms.

IMPORTANT NOTE. PLEASE READ AND SIGN THE FOLLOWING:

I appreciate Kinesiology Practitioners do not give medical diagnosis or treatment.
I understand that my GP is medically responsible for the care of my dependents and myself.
I understand that kinesiology sessions will help to stabilise and normalise my body’s systems which can help the innate design of the body to repair, regulate and function better.
Let me know if you cannot keep an agreed appointment so I can firstly re-schedule with you and secondly offer your therapy session to someone else. On this basis I will need at least 24 hours notice (unless exceptional circumstances), otherwise a minimum charge (75%) will be incurred.

Sending