Full Name
*
First Name
Last Name
Preferred Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Mobile
*
Current Age
*
Star Sign
Please Select
Aries
Taurus
Gemini
Cancer
Leo
Virgo
Libra
Scorpio
Sagittarius
Capricorn
Aquarius
Pisces
Dont Know
Gender
*
Please Select
Male
Female
Non-Binary
Prefer not to say
Other
Other (Gender)
Emergency Contact Name
Emergency Contact Number
How did you hear about Larisa Jayne?
*
Are you pregnant?
Please Select
Yes
No
Not Applicable
Which of these areas are you seeking some assistance with?
*
Describe any significant past history concerning your physical body
*
include any accidents, medical intervention, medication, symptoms, toxin or drug exposure
If you have been experiencing pain, what are the pain levels from 1 - 10?
N/A
1
2
3
4
5
6
7
8
9
10
Type of pain:
e.g. dull, sharp, ache, pins and needles, numbness, stiffness, constant burning, comes and goes
Have you ever been unconscious?
*
Yes
No
Describe any significant past history concerning your mental and emotional life
*
include any major life stresses, traumas or events, as well as any medication or mental and emotional symptoms
Do you take any medications or supplements?
*
If you answered yes to the above question, please list any medications or supplements you take
How often do you drink alcohol
Please Select
Daily
Weekly
Socially
Not Applicable
What other help have you sought so far?
How helpful have they been?
Tick all that are applicable past or present
Other
list any other stressors
Is there any other information that may be relevant to your care that has not been covered?
Declaration
*
I declare that the above information is true and current. The information gathered here and all session records, will remain the property of Larisa Jayne as part of client history and will be securely stored and kept in strict confidence. I further understand that payment is to be made at the time of service and can be made either by cash, Visa or Mastercard. I understand and accept the Clinic Policies regarding late attendance, non-attendance and cancellation and understand that non-attendance or cancellations made within 24 hours will incur a 50% charge of the session fee. PLEASE NOTE FOR ONLINE SESSION: New client session to be paid in full 12 hours prior to commencement of session.
Spinal Energetics can be cathartic, emotional and physical in experience. Touch is made where necessary to help facilitate the release and unravelling of tension in the nervous system. As your brain-body awareness increases, areas of your body that have been disconnected may re-engage. Please be aware this can result in an increase in discomfort and symptoms physically (headaches, increased muscle soreness, stiffness, etc), mentally/emotionally (dropping of mood, feeling fatigued, etc) and/or chemically (toxin release) 24-72 hours after your adjustments.
*
I understand that this service does not replace any medical or psychological advice that I have received from a health care provider and accept that this service is not intended to be relied on for diagnosis or treatment of any medical condition.
*
I understand and confirm that I meet none of the below criteria that is not suitable for Spinal Energetic Sessions;
*
- A person under the age of 12,
- Pregnant
- Detached retina or glaucoma
- Recent fractures or surgeries,
- High Blood Pressure (that is not controlled with medication)
- Recent Cardiac conditions (angina, heart attack, or stoke)
- Diagnosis of aneurysm in the brain or abdomen
- Epilepsy/Seizures
- Hospitalisation for any psychiatric conditions in the past 12 months
- Severe PTSD
Please Sign Full Name
*