Client Intake information - Shamarie Body and Mind Therapies

Name

Date of Birth

Your Current Age

Occupation

Address

Mobile Number

Landline Number

Preferred Contact Method

Emergency Contact Method

Relationship Stauts

Single Married Partnered Divorced Separated Other

Do you Have Private Health Insurance

Yes No

If Yes, What is the Name of the your Insures

Please List any known Allergies or Intolerances

Do you have Any of the Following

High Blood Pressure Breathing Difficulties Diagnosed Medical Health Condition None of the Above

If you have a Diagnosed 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 Search Natural Therapies Pages Other Internet Referred by a friend Facebook other

If you have Filled in this form before making your first appointment, I will contact you shortly.

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

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

Client Intake Form