Please take enough time to fill out this form thoroughly.

YesNo

In the space provided below, tell me a little about what is troubling you.

How long have you noticed this as an issue ?

How would you rate the issues effect on your life? (1 through to 10 ie low through to high)

12345678910

Do you have any concerns about working on this issue?

What would you like to feel and achieve instead?

To support you in achieving what you want;

We will work with you to achieve the changes you wish to see and feel in your life.

We will commit ourselves to providing you with the very best service that we can.

Your records, thoughts and feelings are kept in complete confidence. In fact, unless you greet us out there in public, we will keep our association private.

For the purpose of our ongoing training and development, we may discuss your case during mentoring sessions. No identifying information will be revealed.

Susan Macintosh

Light touch might occur on the hands, shoulders or head as part of a process or intervention. Do you give consent for this to occur?

YesNo

You might be required to work on tasks between sessions for the best outcome. Are you willing to commit to ‘outside’ tasks towards best possible outcome?

YesNo

We may have professional need to communicate with your GP or
referral source. Do you give permission for us to contact your GP,
managing practitioner or referral source if required?

YesNo

I have read and accept the privacy agreement and 2) confirm that I am over 16 years of age

Thank you. I’m so looking forward to getting to know you.

Susan