Client Consultation Form

Your responses to the following questions will enable me to tailor the treatment to your specific needs.

My approach to well-being is holistic and person-centred. This means that I shall take your physical, mental and spiritual health into consideration. The information which you give me will remain confidential, except in rare and extreme circumstances, in which disclosure may be necessary for medical, legal or professional reasons (please see SB Holistic’s terms and conditions for further information). Your completed form and case notes will be stored securely as encrypted computer files, accessible only to your therapist.

As you work through the form, please answer as many questions as you can and include as much information as you can. Some questions are mandatory and cannot be left blank. Before submitting your information, be sure to read & accept SB Holistic’s Terms & Conditions & tick the relevant box to acknowledge this.

Part 1: About You

Title (required)

Your Full Name (required)

What do you like to be called? (if different)

Date of Birth (required)

Your Full Address (required)

Your Full Post Code

Your Telephone Number

Your Mobile Number

Your Email Address (required)

Part 2: Your GP/Doctor

Full Name of your GP

Full Address of your GP (required)

Full Post Code of your GP (if you know it)

Part 3. Additional Information

How did you find out about SB Holistic?

If you used Google, what keyword search term(s) did you enter?

What is your previous experience of massage?

Do you have any likes/dislikes related to massage?

What do you hope to gain from massage?

Have you any specific areas of pain, stiffness or tension which you would like me to work on?

Do you feel at all uncomfortable, nervous or anxious about receiving massage?

Would you like to receive aromatherapy, i.e. massage with essential oils?

Do you live or work closely with someone who has a nut allergy?

Part 4: About Your Health

If you answer ‘yes’ to any of the following questions, then please expand on your answers in the box provided ("Additional information") and give as much information as you can about any existing health conditions, when they were diagnosed, treatment received and any ongoing effects on your life.
Do you suffer from:- Please provide extra details:

Part 5. About Your Lifestyle

Your answers to the following questions will help me to understand how aspects of your life affect your physical and mental well-being. However, if you feel uncomfortable about answering any of these, or you feel that they are not relevant to you, then please feel free to leave them blank.

Who is at home?

Do you look after children or provide care for another adult?

What is your occupation?

How active or sedentary is your work? What activities are involved? How does this affect your body?

Do you experience stress either at home or at work? If so, how does it make you feel physically and emotionally?

How would you describe your diet and fluid intake?

What recreational activities or exercise do you do?

What do you do to relax?

Thank you for taking the time to answer these questions.

Part 6. Confirmation

By completing & returning this form, I give my consent to receive treatment from SB Holistic.

I have read & accept SB Holistic’s Terms & Conditions, including the 48-hour cancellation policy.

Today's Date (required)

Part 7. Anti-Spam Question

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Clinic Address

Exeter Natural Health Centre
Queens Walk
83-84 Queen Street
Exeter
EX4 3RP

Enquiries: 01392 422555

Postage & Packing

Please note: We do not seek to profit from our postage and packaging charges. We acknowledge that our flat rate of £5.99 for UK deliveries may seem high, especially for small orders.

However, our prices accurately reflect the combined costs of Royal Mail postage, plus the labour involved in selecting, packing and dispatching your goods safely to you.

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Website Credits

Text and photographs © 2016 SB Holistic.
Website by Mounsey Web Consultancy
Photography by Sammi Sparke