MICHELLE MIERS

Concomitant Healing Intake Form

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This form helps us to prepare to work with you, and to check we are covering all the important history that could be impacting your current concerns.

As a part of our care for you, it’s important to get an official starting picture of why you are coming to work with us, and your past history. You do not have to answer any questions you don’t want to answer, and if you prefer to discuss them with your counsellor in person, that is perfectly fair and reasonable. Your healer will take a full verbal history from you in your first session, so don’t worry if it doesn’t all fit easily on the form, or if something is complicated to explain. Our privacy approach is outlined at the end of this document. We look forward to supporting you.

Personal Information

Just In Case

Medical History

Have you ever had Concomitant Healing before?

Yes

No

Have you been diagnosed with a mental health condition? E.g. clinical depression, schizophrenia, bi-polar disorder, borderline personality disorder, addictive disorder, eating disorder?

Yes

No

Have you seen a psychologist or psychiatrist?

Yes

No

Have you ever been hospitalised for an emotional illness?

Yes

No

Are you still triggered by previous trauma?

Yes

No

Are you pregnant?

Yes

No

Are you currently seeing any other healing or health practitioner/advisor?

Yes

No

Please indicate if you have any of the following applicable conditions:

Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

Concomitant Healing

During a session of Concomitant Healing you will be touched on various parts of your body by my fingertips and/or hand. You will remain clothed. Do you give consent for me to touch you as described?

Yes

No

Would you like to learn more about Concomitant Healing?

Yes

No

Signature of healing consent:

Clear

If you are under 16 years of age, parent or guardian name and signature of consent:

Clear

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Reply UNSUBSCRIBE to opt-out.

Thank you for participating in answering these questions. I look forward to working with you.

SYNCHRONICITY NATURAL HEALING | ABN: 40 530 783 074 | INSURED BY IICT - ACCREDITED BY SPHINX SPIRITUAL SCHOOL OF LEARNING

All copy is credited to www.concomitanthealing.com