Client Intake information - Shamarie Body and Mind Therapies

Email Address

Name

Address

Occupation

Date of Birth

Your Current Age

Mobile Number

Landline Number

Preferred Contact Method

MobileEmail

Emergency Contact

Relationship Status

SingleMarriedPartneredDivorcedSeparatedOther

Do You Have Private Health Insurance?

YesNo

If Yes, What Is The Name Of Your Insurer

Please List Any Known Allergies Or Intolerances

Do You Have Any Of The Following?

High Blood PressureBreathing DifficultiesDiagnosed Medical Health ConditionDiagnosed Mental Health ConditionNone of the above

If You Have A Diagnosed Medical Or Mental Health Condition Please Describe*

What Is The Name And Telephone Number Of Your Medical Doctor ?

Are You Currently Working With Any Other Therapist ?

Do You Have Any Children ?

Your Main Reason For Seeking Help From Shamarie ?

How Did You Find Shamarie ?

Google SearchNatural Therapies PagesOther InternetReferred by a FriendFaceBookOther

If you have filled in this form before making your first appointment I will contact you shortly

thanks for your interesting in making an appointment with me. I will be my pleasure to help you achieve greater wellbeing and peace of mind.

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Looking for natural, comprehensive and effective approaches to assist you with your Health as well as your Mental and Emotional Wellbeing?

Client Intake Form