Please help me provide you with the best and most effective care possible by taking the time to complete this Health History Form carefully, honestly, and to the best of your knowledge.

All information provided by you, and recorded by me, will be treated with complete confidentiality as per the Australian National Privacy Principals, and will not be used for any purpose other than those stated on this form or discussed with you personally.

Your careful responses to these questions will assist me in ensuring that any risks associated with therapeutic intervention are minimised and that the appropriate care is provided.

Below is a general outline of our standard 1:1 treatment procedure. Please be aware that this is the standard structure for Massage/Bodywork* Sessions, and slight variations may occur depending on your chosen modality (ie. Yoga, Reiki, Sound & Crystal Healing, Counselling etc.)

 

Your session begins when you arrive, and ends when you leave the premises, and includes the brief consultation process prior to treatment, time spent undressing and re-dressing* in the treatment room, the treatment itself, and the de-brief/after-care advice following treatment. Please consider these factors when choosing your desired session length.

Upon your arrival, the practitioner will review and discuss your Health History details with you and determine a therapeutic strategy that is appropriate for your needs, preferences, and intentions, and within the bounds of the practitioners’ scope of practice. The practitioner will explain the proposed treatment plan to you, and your consent to the plan will be sought in the form of a verbal agreement, and the implied consent provided when participating in the treatment process (disrobing*, lying on the table, etc). Instructions about the assessment and treatment procedure, the areas of the body to be treated, the disrobing and draping procedures*, and set-up and positioning options will all be discussed with you prior to the commencement of the treatment to ensure your clear understanding of the processes and procedures, and to offer you the opportunity to ask questions or request changes. You can alter treatment plans, request adaptions to the treatment, positioning, and pressure*, or choose to withdraw your consent for treatment at any time. Signing this Health History Form, or the Terms and Conditions Agreement, does not remove you right to withdraw from any option the practitioner may offer now or in the future.

Once the treatment is complete, you will have the opportunity to discuss the session, ask questions, and request further adaptations to future treatments. The practitioner may recommend stretches or exercises to assist with integration, recovery, and supporting yourself between sessions. All aftercare advice and recommendations are important factors in determining the likely success of your care, and like all healthcare modalities, results are not guaranteed, and responses to and results from treatment vary from client to client.

Please read and sign the following, acknowledging that all information you have provided is true and, to the best of your knowledge, accurate and up to date, and that you understand the treatment processes and procedures and give your consent for treatment to be conducted.

I consent to the treatment being carried out by Chloe Thomas, understanding that she is a qualified and insured Remedial Massage Therapist, Reflexologist, Reiki Practitioner, Ka Huna Bodyworker, Yoga & Meditation Teacher, Shamanic Healer, and Myofascial Cupping Practitioner possessing all the required qualifications and documentation, which can be produced or discussed upon request.

I intend for this consent to cover the entire course of treatment for my present condition, as well as any conditions for which I seek therapeutic intervention in the future, and I verify that all health and personal information I have provided is honest and, to the best of my knowledge, accurate and up to date.

Please read and sign the following, acknowledging that you understand and accept the terms and conditions of your treatment and our provision of services.

• I must NEVER attempt to solicit sexual services from the practitioner! ALL inappropriate, disrespectful, offensive, or threatening behaviour, will result in my IMMEDIATE expulsion from the premises, the cancelation of any pre-booked appointments, a lifetime ban from attending all Sacred Hearth appointments, classes, events and workshops, and the potential filing of a police report.

 

• I am not welcome to visit the Sacred Hearthbusiness location without an appointment or prior approval! The studio location is a home before it is a business, and it is important for me to observe and respect this personal boundary. I will ALWAYS ensure that I have a scheduled appointment before attending the premises and will not arrive earlier than my scheduled appointment unless I have sought and received, either by phone or email, prior permission. If I seek permission and do not receive a response, then I will assume that I do not have permission and will arrive at my original scheduled appointment time. If I do not have an appointment, then I do not have permission to be on the premises and I will be asked to leave. If I attend the premises without permission and my behaviour is in any way inappropriate, disrespectful, offensive, or threatening, then the police will be contacted without hesitation.

 

• Sacred Hearth and its practitioners have the right to refuse service to anyone for any reason providing that refusal does not violate anti-discrimination laws.

 

• I am responsible for my own appointments. All text and email confirmations and reminders are a courtesy. At least 24 hours’ notice is required when cancelling or rescheduling an appointment. If I cancel within 24 hours of my appointment, I am financially obligated to pay 50% of the total service fee. If I cancel within 12 hours of my appointment, or I miss it entirely without notice, I am financially obligated to pay 100% of the total service fee. Late arrivals will incur the full appointment fee, regardless of treatment length upon arrival. All outstanding fees must be paid before any further treatment will be provided.

 

• I am financially obligated to pay the set service fee prior to the commencement of my treatment. The practitioner is under no obligation to offer refunds or discounts if I feel I am entitled or unsatisfied.

 

• Sacred Hearth is a Natural Complimentary Therapy practice, not a Medical Clinic, therefore the practitioner does not diagnose illness, disease, or other physical, mental, or psychological disorders. As such, the practitioner neither prescribes medical nor pharmaceutical treatment, or any form of supplement. However, they may prescribe stretches and or exercises to assist with the care and treatment of joint and muscular dysfunction.

 

• Sacred Hearth is legally required to collect and store both contact information and detailed health histories for ALL clients attending 1:1 appointments. I am required to inform the practitioner of all medical conditions that I may be suffering from, including (but not limited to) injuries, physical/mental illness, recent surgeries or medical treatments, and medications being taken, and I am required to keep this information up to date by informing the practitioner of any changes to the information I provided as of my last visit.

 

• Hygiene and infection control procedures are in place to protect me, the practitioner, and others who may attend the studio, however, the practitioner cannot be expected to anticipate or guard against all potential risks associated with therapeutic intervention. By providing accurate information regarding my own health, I assist the studio in reducing potential risks.

 

• I accept responsibility for my own health and wellbeing. Sacred Hearth’s wellness therapies are not a substitutefor personal responsibility. They do not cure illness, disease, or dysfunction, nor do they claim to. If I am seeking therapeutic intervention as a means of absolving myself of personal responsibility, I may be asked to seek alternative healthcare services.

I verify that I have read, understood, and accepted all the Terms and Conditions of my treatment, and the provision of services.