Energetic Health Assessment

Personal Details, Medical History and Indemnity
Stress Or Trauma?
Habits?
Chronic pain?
Have you had any?
Chronic medication?
Have you been Covid-19 vaccinated?
Do you have?
Do any of the following physical conditions currently affect you?
Do any of the following Mental/Emotional conditions currently affect you?

Confidentiality Clause

Everything discussed within the confines of the time of our work together, shall remain confidential and shall not be divulged to any third party by you or your therapist.

 

Cancellation Clause

I agree to give a minimum of 24 hours cancellation notice if the session is to be cancelled or changed. Failure to do so will result in full payment of the missed session.   

 

Indemnity

I undertake this treatment of my own accord and accordingly indemnify the therapist from any harm, loss or damages of any nature, whether bodily harm, trauma or any other damages to my person or property resulting from the treatment, whether directly or indirectly. 

 

Bookings

This form has to be completed before a session and all conditions need to be accepted. 

POPIA

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Covid-19 health Declaration

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