Intake FormPlease fill the required fields. Have you ever suffered from the following? (Please tick) EpilepsyDepressionFearsObsessionHigh/Low Blood Pressure BreakdownHeadachesFatigueDiabetesHypoglcaemia UlcersInsomniaNightmaresAnxiety I have read and accept the terms and conditions as stated here. To the best of my knowledge, the information given is true and correct and I hereby declare that I attend this session of my own free will and take full responsibility for my own well-being.