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.
