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All About You Wellness Centre Client Information Sheet for Public Speaking Date *Name *FirstLastOccupation *Date of Birth *Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryHK ID Card/ Passport Number *Contact Numbers *Email *Gender *MaleFemaleNon – BinaryPrefer not to sayHave you ever spoken in public before? *YesNoIf yes, how would you describe your experience?What parts of public speaking do you feel you would like support with? *Delivery and StyleFear and MindsetAn upcoming speechStructure & ContentPowerPointOther (please state)Describe in your own words what you would like to accomplish out of your Public Speaking Coaching session(s)? *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.I have read and accepted the above terms and conditions above.(This agreement is valid from the date signed until further notice.)Client Name *FirstLastPlease type your name to confirm all the information above. This will serve as your e-Signature. *Date Signed *Submit