First Name
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Last Name
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Street Address
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Suburb
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Postcode
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Email
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Phone
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Occupation
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Date of Birth
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Referred by:
Preferred Method of Contact
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Would you prefer?
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Have you heard of?
Tick all that apply
If any of the above would be suitable post consultation, are you open to me sharing the benefits?
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Yes
No
Please mark if any of the below applies:
Select all that apply
Please expand on any of the above.
Please indicate any areas of physical/emotional tension, discomfort or injury you have in the body:
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Any current illness/conditions? Please expand.
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Are you aware of any hereditary diseases?
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Yes
No
Leading into when your physical ailments presented was there a specific emotional connection at the time (grief, anger, loss, trauma, stress etc)?
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Yes
No
Please expand if you feel comfortable:
Are you comfortable with an eye pillow?
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Yes
No
Do you like music playing with no lyrics?
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Yes
No
Would you prefer no music playing?
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Yes
No
What is you preferred touch pressure?
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Light
Medium
Firm
What areas should we focus on?
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Select all that apply
Any areas you would like more attention spent?
Any areas you would prefer be avoided?
In past treatments what have you loved?
In the past what have you not enjoyed?
On a scale of 1 - 10 rate how physically tired you feel
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1 being minimal and 10 being extreme
On a scale of 1 - 10 rate how emotionally tired you feel
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1 being minimal and 10 being extreme
On a scale of 1 - 10 rate how stressed are you
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1 being minimal and 10 being extreme
On a scale of 1 - 10 rate how would you rate your energy levels?
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1 being minimal and 10 being extreme
What symptoms are you experiencing?
Select all that apply
In the last 3 months have you had?
Select all that apply
Were the following needs met in your formative years (0-21)?
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Select all that apply
In the last 3 months have you recognised?
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Select all that apply
How many hours of sleep are you getting on average?
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5+
7+
9+
Average bed time?
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Average rise time?
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Do you rise naturally or use an alarm?
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Rise Naturally
Alarm
Do you wake up through the night?
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Yes
No
Do you find it hard to go back to sleep?
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Yes
No
Do you wake up tired?
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Yes
No
Do you suffer from insomnia?
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Yes
No
Do you have any discomfort at these times or wake up through the night?
Select all that apply
Do you experience any of the following:
Select all that apply
Do you seek support from:
Select all that apply
We know many amazing people in these fields, would you be open to recommendations?
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Yes
No
I give full consent for Jansie Sonter to perform today’s treatment. I have disclosed all relevant medical history, medications and current symptoms prior to treatment. I understand that withholding information or providing misinformation can impact my results with treatments. All advice given regarding treatment, product, wellness tools, lifestyle and diet suggestions only. I have had the opportunity to ask questions about this consultation form. I understand I am required to notify my therapist of any changes to my health or if I am uncomfortable with any part of my treatment today or in the future. I am aware that I need to consult with my Healthcare provider prior to receiving treatments if I am experiencing any contraindicated conditions in which it would be unadvisable to receive this treatment.
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