Client Intake Form: Complementary Therapies

Client Full Name(required)

Preferred Name (if different from above)

Name of Person Completing the Form (if not the Client) & Relationship to the Client

Client Date of Birth and Age (DD/MM/YYYY, XX)(required)

Today's date (Date completing this form)(required)

Address including Postcode(required)

Contact details of the client, or parent/guardian if the client is aged 16 or younger.

Email(required)

Mobile Phone Number(required)

Home Phone Number

All the fields below are required to submit this form. If any fields do not apply to you/are not relevant, please type “none” or “N/A”.

Mental Health Issues Past/Present, such as anxiety, depression, bipolar disorder, self-harm or suicidal ideation, trauma, risky behaviour (please state if any of these have been diagnosed by a medical professional & when)(required)

Medical/Physical Issues Past/Present(required)

Sleep Issues (incl. average hours sleep per night)(required)

Appetite Issues (good/bad, healthy/unhealthy)(required)

Why have you chosen this type of complementary therapy?(required)

If you are completing this on behalf of a client aged 16 or under, are they aware of this? YES / NO(required)

If YES how does the client feel about this complementary therapy? If NO please explain why the client is not aware of this referral?(required)

Electronic Signature: You can complete the box below which we will accept as your e-signature. If you would prefer, you can download this form here and either digitally sign it, or print, sign and scan/photograph it and email it to us at holistichealthyork@gmail.com.

Signature (please type your name in the box)(required)

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