Consultation Form

Please note everything is confidential between therapist and client. You can write as much or as little as you like. It is for your own healing path.

BOX A

For Children U.16 only fill box A, B and C

Name

Age

DOB

Street Address

City

County

Eircode

Occupation

Phone

Email Address

How did you hear about us?

Emergency contact name and number

GP name and contact details

If you were referred please indicate the name of the person who referred you?

Close family members passed

Close family members alive

BOX C

For Children U.16 only fill box A, B and C

Your intention for healing - please be specific about your healing goals

Your Current PHYSCIAL symptoms / pain / illness/ allergies etc severity and duration - please be as detailed as you can

Your CURRENT emotional symptoms /feelings/mood/thought etc- severity and duration - please be as detailed as you can

Are you on any medication? (including contraception / dosage and duration ) or have you been in the past?

Have you experienced delusions/hallucinations/psychosis or had suicidal thoughts in the last 5 years or have attempted suicide or diagnosed with a mental health issue?

History of trauma in your life including childhood (birth trauma, physical abuse, emotional abuse, sexual abuse, other)

History of surgeries, hospitalisation, non surgical interventions for your health etc

Please specify in detail what drugs / alcohol you are using and frequency

Other notes e.g family incidents or major events or triggers in your life or history

What other therapies are you currently using or have tried in the past?

Lifestyle -please mention your exercise, diet, movement practises, spiritual practises

Date

Signature

Consultation Form

Consultation Form

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