📢 Welcome to Keep A Lid On It! Before we book your session, please fill out this form so we can best support you.

🔹 Personal Details

Full Name: ___________________________
Date of Birth: //______
Phone Number: _______________________
Email Address: _______________________
Preferred Contact Method: 📞 Call / 📩 Text / 📧 Email
Emergency Contact Name & Number: _______________________

🔹 Appointment Preferences

Which therapy/modality are you interested in?
☑️ Tapping (EFT)
☑️ Hypnotherapy
☑️ Kinesiology
☑️ Reiki
☑️ Access Bars
☑️ Chinese Medicine
☑️ Feng Shui Consultation
☑️ Family Constellations
☑️ Other (please specify) _______________________

Preferred Appointment Date & Time: _______________________

🔹 Health & Well-being

1️⃣ Are you currently under the care of a doctor, therapist, or specialist?
☑️ Yes
☑️ No

2️⃣ Are you currently taking any medication?
☑️ Yes (please list below)
☑️ No

Medications (if applicable): _______________________

3️⃣ Do you have any medical conditions we should be aware of?
☑️ Yes (please specify) _______________________
☑️ No

4️⃣ Have you had any prior experience with holistic therapies?
☑️ Yes (which ones?) _______________________
☑️ No, this is my first time!

🔹 Consent & Disclaimer

🔹 By booking a session, you acknowledge that our services are holistic and complementary in nature.
🔹 We do not diagnose, treat, or replace medical advice, prescriptions, or doctor recommendations.
🔹 If you are under medical care, please consult your healthcare provider before making any changes.
🔹 All information provided is confidential and used solely for your session.

☑️ I acknowledge and agree to the above terms.

Signature: _______________________
Date: //______

📍 Once submitted, we will review your form and confirm your appointment. We look forward to working with you! 😊

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