Client Intake Form – Pain Relief & Trauma Release with Hafsa Khan

All About You Wellness Centre

Client Information Form

Name : *

First

Last

Date of Birth *

Other Contact Number:

Email: *

Emergency Contact Name *

First

Last

Phone number incase of emergency

Health History

Current Physical Health Issues (chronic pain, injuries,etc.)

Medical Conditions(note any relevant conditions)

Joint problems

Allergy

Cartilage problems

Cancer

Females Only

Checkboxes

Menopause
Premenopause
Endometriosis
Hormone problems

Medication (list current medications and their purposes) *

Previous Therapies or Treatments(any past physical or emotional therapies) *

Surgery History (previous surgeries and dates) *

Lifestyle Information - Physical Activity Level

sedentary
moderate
active

Social activities

Drinking Alcohol (how many glasses per week )

Drinking Coffee (how many cups per day)

Drinking water (how many glasses per day)

Do you smoke ? *

Occupation(job title, physical demands of the job)

Stress Levels (scale of 1-10)

Sleep Patterns (hours of sleep, quality of sleep)

Emotional History

Current Emotional Challenges(stress, anxiety, depression, etc.) *

Recent Life Changes (loss, trauma, major life events) *

Coping Mechanisms(how they handle stress or emotional pain) *

Energy Awareness

Current Energy Levels (scale of 1-10)

Physical Sensations(any sensations you typically feel in their body related to energy) *

*Energy Practices* (any practices you engage in, such as meditation, tai chi, prayet yoga, or Reiki) *

Past Experiences with Energy medicine (previous sessions or modalities experienced) *

Emotional and Spiritual Considerations

Exploration of Emotions (specific emotions you want to address or understand) *

Spiritual Beliefs (any spiritual , faith or holistic practices you may follow) *

Support Resources

Current Therapies (are you already undergoing therapy or counseling?) *

Interventions That Have Worked (previous therapies or approaches you felt helped you) *

Goals for Therapy

What do you hope to achieve (pain relief, emotional release, trauma healing , relaxation etc) *

Preferred Techniques (any specific methods they are interested in) *

Frequency of Sessions (how often they wish to receive treatment) *

Overall Wellness Goals

Physical Goals (what physical issues you want to address) *

Emotional Goals(what emotional healing you seek) *

Spiritual Goals (any areas of spiritual growth you are interested in) *

Terms and Conditions

Cancellations must be made at least 24 hours prior to the scheduled appointment. If cancellations are made less than 24 hours the full session fee will be charged. Should the client fail to show up, the full session fee will be charged.
All prior payments are non-refundable and non-transferable, except in special circumstances and All About You (‘AAY’) reserves the right to the final decision.
The Client agrees that all practices done on, for, or even by them at AAY are done with their full consent and at their will.
The Client attests that they have no mental or psychological ailment/disorder and are not on any psychiatric or psychological treatments and/or drugs.
The Client agrees to indemnify, release, remise and forever discharge, the treating practitioner, AAY, its employees, its consultants, its property owners or anyone one at AAY from any obligation or liability whatsoever, all claims, demands, damages, injuries, actions or causes of actions whatsoever, before, during or after volunteering to participate in such sessions.
The Client is aware of the modalities of therapy used and understands that the result may also depend on external factors and the clients’ own efforts.

Privacy
By signing this form, you understand and agree: Your personal data (name, contact details, interests) may be used by AAY to contact you and inform you about our latest news, events, promotions, offers, workshops, seminars and other exciting happenings at AAY. Please note that you may change your mind at any time and ‘opt-out’ of our mailing list by either writing to us at info@soniasamtani.com or by clicking ‘Unsubscribe’ in any of our email communications.

Confidentiality
All information discussed in the sessions will be treated as confidential information and will not be disclosed to any third party unless prior permission is granted or unless disclosure is required by law. However, counselors are ethically and/or legally required to disclose confidential information to the appropriate authorities in four kinds of circumstances:

● If a client indicates that they or another person may be a danger to themselves or others
● In the case of apparent, suspected or potential child abuse or neglect
● If clients report sexual abuse by a regulated health professional
● When a court issues a summons for records of testimony

From time to time your practitioner may consult another for supervision, in order to improve the quality of services provided, without using personally identifiable information. Other than the four circumstances listed above, your practitioner cannot converse, write or give any information about you or your circumstance, without your verbal or written informed consent to do so.

General – Informed Consent
The purpose of your sessions here is to help you improve your current circumstance(s) and our aim is to contribute to your well-being and growth. Sessions involve delving deep into the root of the problem/s and it is not uncommon for clients to feel an increase in symptoms before they feel better. However, the potential benefits of counseling are numerous. Should you have any questions, concerns or suggestions regarding the information provided above or any other aspect of the counseling process, feel free to discuss with your practitioner. Should you choose to discontinue sessions at any time it is highly advisable to discuss the reasons for considering this with your practitioner prior to acting on your decision.

I have read and accepted the above terms and conditions above.

(This agreement is valid from the date signed until further notice.)

Please type your name to confirm all the information above. This will serve as your e-Signature.

Date Signed: *