Full Name *

First Name

Last Name

Which of these areas are you seeking some assistance with? *

Relief / Improvement from physical symptoms

Improvement of emotional / mental well-being

Greater ability to manage relationships

Greater ability to manage stress

Improve posture and mobility

Personal / Spiritual growth and development

Greater life enjoyment

Improved overall health and well-being

Mindset / Belief shifts

Embodiment

Do you take any medications or supplements? *

Yes

No

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 for prior to commencement of booking.

I Agree

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 acknowledge that I have read and understood the above