New Client Form

Thank you for taking the time to complete the form below. Answering these questions will allow me to better understand why you are here and how I can best serve you as a Spinal Energetics practitioner. If you are unable to answer a question/s simply write N/A in the space provided.

Confidentiality:

We take confidentiality very seriously at Lady Harmony. Your responses will be kept 100% confidential and the information provided will only ever be used for the sole purpose of Spinal Energetics.
New Client Form

Spinal Energetics with Tanya Elise at Lady Harmony
Your Personal Details:
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please include your Area Code. For example: (+61), (+49), (+91), (+44), (+33), (+39), (+52) etc.
Your Time Zone*
Eg: Melbourne (GMT+11) or Los Angeles, CA, USA (GMT-8) or Dublin, County Dublin, Ireland (GMT) etc.
Best Emergency Contact Name*
Best Emergency Contact Phone Number*
Please include your Area Code. For example: (+61), (+49), (+91), (+44), (+33), (+39), (+52) etc.
How Did You Hear About Us? (Please include client name if referral)*
Have You Experienced Spinal Energetics Before?*
Clarity Questions:
From the following options, tick 3 main areas that you are seeking relief/clarity/healing:

Physical BodyMental BodyEmotional BodySpiritual BodyPersonal Soul
From the following options, tick 5 main areas that you are seeking relief/clarity/healing:

Reduce Physical Pain, Tension, and StressImprove Spinal Health, Posture, and FlexibilityReduce Mental Chatter and OverthinkingImprove Sleep QualityRelease Repressed EmotionsImprove Fear State (Flight, Fight, Freeze, Fawn State)Strengthen The Mind, Body, Soul ConnectionStrengthen IntuitionGain Clarity and MeaningForgive and Release The Past
List 1-5 main reasons for your visit in your own words:
What type of practitioners and health care providers have you consulted in the past and how helpful have they been?
Who do you currently have on your health team and how long have you been seeing them for? (i.e. Naturopath, Nutritionist, Psychologist, Life Coach etc).
If you partake in any of the follow activities, tick them below:

YogaPilatesMeditationBreathworkCryotherapy (Cold Therapy)Personal TrainingGym, Including ClassesWalkingRunningCyclingSwimming
List any other activities that you enjoy that haven't been listed above:
Physical Questions:
How often do you consume alcohol?

NeverLess than monthlyMonthlyWeeklyDaily
How often do you partake in recreational drug use?

NeverLess than monthlyMonthlyWeeklyDaily
How would you rate your overall physical health?

PoorOkayGoodVery GoodExcellent
If you have any current or reoccurring physical pain in your body, list them below and rate the levels of pain from 1-10:
What does the pain feel like:

SharpDull AcheBurningPins and NeedlesNumbnessStiffnessConstantIntermittentWeakness
Share any significant current and past medical, surgical history, including heart/inflammation/pain medications, allergies and reactions:
Mindful Questions:
How would you rate your overall emotional and mental health?

PoorOkayGoodVery GoodExcellent
Share any current or past emotional and metal health challenges, diagnoses and medications:
On a scale from 1-10 how would you rate your sleep? Do you have trouble falling asleep and/or staying asleep?
What would your main goal/s for the future be for your physical, mental, and emotional life?
Is there any other information that you feel may be relevant to your care at Lady Harmony that has not been covered?
Medical Disclaimer, Terms and Conditions:

Lady Harmony (ABN 15496098071)
By signing this form I am confirming that I have read and understood the Medical Disclaimer, Terms of Use, and Release of Liability Waiver, along with the Cancelation, No-Show, and Refund Policy provided by Lady Harmony *

Clear
Should be Empty:

New Client Form

Your Personal Details:

Clarity Questions:

Physical Questions:

Mindful Questions:

Medical Disclaimer, Terms and Conditions: