Thank you for inviting me to be part of your heath and wellness support, I am excited to be working with you.
Please complete this form as honestly as you can, if there is anything you don't feel you can write here, please feel free to let me know later as you place your trust in me.
The more information you can give the better, these questions offer a framework, but if you have a long complex medical history, you may wish to type it out and send me that as a separate file, which you can upload at the bottom of this form. Sometimes just sitting down to write your history so far, realising and acknowledging how far you have come can be very helpful in itself.
To comply with GDPR regulations: I aknowledge and have given my personal details for the therapist. I understand that my information is protected and I give my consent to Rev. Cynthia Keating to store and use my details are set out by the GDPR guidelines.
I understand that if I have been untruthful with my details or have failed to give enough pertinent information any treatment could be adversely affected..
I acknowledge that Rev. Cynthia Keating does not claim to cure or to diagnose any medical condition in the same regard as a physician as her professional opinion is that of a holistic therapist.
I will seek the advice of Doctor or other medically qualified Health provider in the case of a medical emergency medical ailments or in respect to general health questions without delay.
If there is a change to my medical information in the future, I will update Cynthia of same, as it has been explained to me there are contraindications regarding certain conditions and illnesses.