General Consultation Form

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. 

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

GP Name and Surgery *

If you work, what do you do?*

Any medical conditions?*

Please give more details about any issues mentioned above, including when you have suffered, for how long, what helps, what makes things worse etc.

Are you taking any prescribed medication? If so give details.

Are you taking any herbal supplements or vitamins? If so give details

Do you have any allergies?*

How are your stress and anxiety levels?*

How are your energy levels?*

How are your sleep patterns, do you get to sleep easily and stay asleep, or do you wake in the night?*

Any past surgical operations or serious illnesses?*

Have you tried any other complementary therapies or do you receive treatments from any other practitioners?*

Have you had any pregnancies, miscarriages or terminations? Please give details.*

How are you hoping I can help you?

What changes would you like to achieve in the next 6 months?*

Is there anything else you wish to share with me, or think I should know?*

DISCLAIMER: Rev. Cynthia Keating is not a Medical Doctor or Psychiatrist and the services provided are not a substitute for professional legal, financial, medical or psychiatric advice or care. One should always seek a Licensed Physician, Psychiatrist or Counsellor for diagnosis and treatment. If you are in need of immediate professional assistance (i.e. doctor, psychiatrist, lawyer, financial advisor, etc.), please seek it. Personal choices and/or actions based on the content of your session or service are solely your responsibility. If you are currently facing a life crises, it is recommended that you seek appropriate professionals to assist you. Rev. Cynthia Keating is not responsible nor liable for your emotional or physical state of being. You understand that by booking an appointment with Rev. Cynthia Keating, you are paying for her time. In the event that you are unable to make your appointment, at least 24 hour cancellation notice is required. Appointments cancelled with less then 24 hours notice will be charged 50% of the booked treatment cost. Less then 24 hours notice must be submitted in writing to; info@cynthiakeating.com. At least 24hrs notice is required to reschedule appointments. In the event that Rev. Cynthia Keating has to reschedule your appointment you will be given the option to: A) Reschedule your appointment to the next available time that works for you. B) Receive a full refund for your session. If you are running late for any reason, Rev. Cynthia Keating will hold your appointment for 5 minutes. After that you will need to reschedule and you will be charged the full amount of your service. There is a 5 minute grace period with all appointments. I have had the procedure explained to me and I understand the nature of the treatment. I fully understand this treatment is not a substitute for medical treatment and it may take several sessions before I notice any benefit. This will depend on my lifestyle and general health. I understand the information which I have given to be the truth and consent to the blended treatments of Cranial Sacral Therapy, Gentle Release Therapy, Healing energy (Qi) and McLoughlin Scar Tissue Release®.

Signature

Parent Disclimer: (Please sign if you are leaving a child in my care): I acknowledge that ....................................... has expressed his/her wish to be independent during the session. I agree to leave my child in the care of Cynthia Keating for the duration of his/her treatment and any future treatments.

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