Consultation Form

Please provide me with the following details. These details are for use solely for the purpose of giving you a safe and beneficial session. These details will held on a secure server and used for no other purpose.

By submitting this form you are declaring that you have not withheld any information that has been requested for your own safety.

“I understand that this form of therapy is not a substitute for medical or psychological diagnosis or treatment. It is recommended that I see a registered Doctor or appropriate health care professional for any physical or psychological condition that I have.”

“I understand that any action I take or do not take as a result of this therapy is entirely my own choice and responsibility.”