Client Intake Form

Client Intake Form

Leigh Whiteside
Customer Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City/TownCounty/State / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Name of GP & GP Surgery:

GPSurgery address & telephone number
How did you hear about me?*
Please tell me your reasons for seeking an activation/healing/hypnosis session with me.
Please describe any underlying physical and/or mental health issues, medical conditions and allergies, past and present,which you have:
Please list any medication you are currently taking, or have taken within the last year, including what it’s for:
Do you have a pressing issue or challenge that you would like to start with? Please note you do not have to disclose anything here if you do not wish, simply writing block, emotional issue or fear is enough.
Has this been a pattern or theme in your life?
Please list any other background information, including any other therapy/therapies experienced in the past or currently:
Any other information you wish to let me know?
Are you currently pregnant?

YesNoMaybe
Disclaimer: ALL information provided here will be kept completely confidential.
Energy healing/alchemy/activations/hypnotherapy work towards increasing overall wellbeing.
A healing session is not to be seen as a substitute for medical diagnosis or treatment.
It is important that you continue any treatment programme, medication or care already put in place by your doctor or other medical specialists.
Please do not discontinue medication or make any important changes without consulting your doctor.
Tell your Doctor that you have been having healing sessions.
Please take full responsibility for your own wellbeing if you choose to have healing with me.
I agree to all that is stated above -
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