HOLISTIC THERAPY CLIENT FORM

Thank you for taking the first step towards your wellbeing. Holistic counselling is a compassionate and client centered approach that recognises the connection between the mind, body, and spirit. Together, we'll create a safe and supportive space to explore your experiences, tap into your nervous system and core beliefs, develop self-awareness, and cultivate practical tools that encourage healing, resilience, and personal growth.

Areas of support:

Grief and Loss
Stress & Burnout
Self-doubt
Mental health & Emotional wellbeing
Mindfulness

Prices

1 Hour Standard Session – $120

5 Session Package – $450
Designed for ongoing support and deeper personal growth.

10 Session Package – $850
A comprehensive healing journey with consistent guidance and accountability.

Full Name

First NameLast Name

Date of Birth

Date

Gender

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

GP Name

GP Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you currently taking any medication?

If yes, please specify the medication(s):

How would you describe your current physical health?

Please list any current or past medical conditions relevant to your wellbeing.

What problems/concerns are you seeking guidance for?

What is your desired outcome? (i.e. what do you hope to accomplish during our time working together?)

Which days/times suit you?

Have you received professional treatment for your concerns before?

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Typed Name

I _________ agree that the above information is true and correct and hereby consent to Holistic Counselling/Coaching. I understand that I am not being given medical advice/treatment from the practitioner. I agree that I take full responsibility for my health, and that I am committed to achieving my desired goal with my therapist. I acknowledge that my therapist adheres to non-discriminatory practices and guidelines.

Signature

Date