Holistic Treatment Client Consultation Form Treatment Client Consultation Form Client Aftercare Information: It is important that following your treatment you drink plenty of water and take care to

Download Holistic Treatment Client Consultation Form  Treatment Client Consultation Form Client Aftercare Information: It is important that following your treatment you drink plenty of water and take care to

Post on 31-Mar-2018




1 download


Holistic Treatment Client Consultation FormDate: _________________________________________________________________Name: ________________________________________________________________Address: ______________________________________________________________Phone # / E-mail: _______________________________________________________D.O.B: ________________________________________________________________Please complete the following questions. Please be assured that the information that you give iscompletely confidential and held in accordance with Data Protection Legislation. All information gathered is used to inform and safeguard the therapy you receive.Reflexology is a holistic therapy. Through the application of steady, even pressure using specificthumb and finger techniques, reflexology connects with the peripheral nervous system and encourages the body to relax. Feet mirror the body and each reflex point connects with a specific organ, gland, body part, or body system. Current Health Issues:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Aspirations for the treatment? / What outcome are you seeking for this visit?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Occupation: __________________________________________________________________Lifestyle (exercise, activities, diet, vitamins, etc.): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other forms of Holistic Healing / Bodywork: _________________________________________Are you under stress? Rate 1-5 (5 high stress) At work? __________ At home? ___________Do you have headaches? Yes / No How often?_____ Relieving factors?_______________Do you sleep well? Yes / No Problems falling asleep? Once asleep, waking? How often? Do you wake feeling rested? ____________________________________________________________________________Client Consultation Form Page 1Holistic Treatment Client Consultation FormMedical HistoryAre you currently under medical supervision yes / noDetails:________________________________________________________________Are you currently on any medication? yes / noIf yes, are there any side effects I need to be aware of?__________________________Are you currently pregnant? yes / noDo you have menstrual / menopausal problems? Explain: _________________ yes / noAre you living with any of the following conditions?Epilepsy / Diabetes / Drug or Alcohol Dependency / Allergies / Low Blood PressureDo you have any joint problems? (Arthritis, etc.) Where? __________________ yes / noHow is your spine? (neck / mid back / low back) _______________________________Do you have any foot problems / concerns? Explain: ____________________________Any current tender spots on your feet? Explain: ________________________________Are you aware of any other condition that may affect your treatment? yes / noIf yes, please comment: __________________________________________________To the best of my knowledge the above information is correct and I am okay with being gently touched appropriately by the practioner during the treatment. I understand that this holistic treatment is a stress reduction and relaxation technique that may overcome or ease a broad range of ailments, disorders, or pain. I acknowledge that sessions administered are only for the purpose of helping me relax, relieve stress, and release blocked energy. I understand that Holistic Therapists do not diagnose conditions, nor do they prescribe substances or perform medical treatment, or interfere with the treatment of a licensed health care professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have.I also understand that the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body toreach the level of relaxation necessary to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of Holistic Therapy.Signed: ___________________________________ Dated: __________________________Client Consultation Form Page 2Holistic Treatment Client Consultation FormClient Aftercare Information:It is important that following your treatment you drink plenty of water and take care to follow any of the specific instructions your therapist has given you.Some people have an abundance of energy after a treatment while others may feel lethargic. Both feeling are perfectly normal. In extreme cases the treatment has caused a significant shift to a blockage and may result in an increase in urination or bowel movements again, this is perfectly normal and in fact, a good indication that the therapy is working. However, if you do not experience this, it doesnt mean to say that the treatment has not been effective, as everyone will respond differently. Allow yourself to relax and take time for yourself if at all possible. It is important to contact your therapist and doctor immediately should you feel any unusual sensations you are worried about. Your therapist is not a doctor and does not diagnose so it is important to get the advice of your doctor regarding medical questions.Most of all, allow yourself to enjoy the wonderful benefits that your therapy will bring. Behappy knowing that you are taking steps to better your health and improve your quality of life.Research has proven that the following advice helps to improve health and well-being: Drink plenty of water Regular meditation Regular exercise Avoidance of alcohol (particularly before and after a treatment) Avoidance of caffeine e/g tea/coffee. Herbal teas are a good alternative If a smoker, try to reduce the number of cigarettes you smoke Eat light regular meals with plenty of fruit and vegetables Make quality time for yourself for rest and relaxationClient Consultation Form Page 3


View more >