PERSONAL DETAILS

Your full name (required)

Date of Birth (required)

Address (required)

Suburb (required)

Postcode (required)

State (required)

Country (required)

Home phone number

Business phone number

Mobile phone number

Occupation (If unemployed please state previous employment if any)

Relationship status

Partners name

Partners age

Partners occupation

Children's names and ages

Your E-mail (required)

Medical history

Name of present doctor and phone number

Is your doctor aware of this appointment?
YesNo

Do you have a referral from a doctor?
YesNo

Current medication

Do you have medical insurance with extras?
YesNo

If yes, what fund and schedule?

Have you ever been hospitalised? If yes, please explain the nature of the illness, when and for how long

Have you ever suffered from the following.

(please tick)

EpilepsyDepressionFearsObsessionsUlcersInsomniaNightmaresAnxietyBreakdownHeadachesFatigueHypoglycemiaHigh/Low blood pressure

Do you smoke?
YesNo

If yes, How many per day? Do you want to stop? Why?

Have you ever had shock treatment?
YesNo

If Yes, When? Why?

Do you practice meditation/yoga?
YesNo

Are you currently consulting any other practitioner in relation to your consultation today?
YesNo

If yes, what is the practitioner's name and phone number?

Would you like us to co-ordinate our treatment with them?
YesNo

Have you ever been hypnotised? Please briefly explain your experience

Briefly why have you booked a session and what do you hope to achieve?

To the best of my knowledge, the above information 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

TERMS AND CONDITIONS

1. The services provided at Soul’s Destiny are very real, profound and unique. As a result, we have limited appointment times available. If
you are not completely dedicated to creating real change in both your inner world and outer world then please don’t take up an appointment time and take this opportunity away from someone that is. If this is the case, we genuinely wish you well and welcome you when you are ready.

2. We vow to make your change and healing our priority. We ask that you do the same.

3. We promise to treat you with consideration and respect by not cancelling or moving your appointment unless absolutely necessary. We ask the same of you.

4 Initial appointments require a deposit of $50. Any appointments over 2 hours require a deposit of $100. Deposits are nonrefundable. Appointments may be changed with no loss of deposit if 48 hours notice is given. (We understand that sometimes life throws unexpected curve balls and can be flexible in such circumstances).
Deposits can be paid by card or direct deposit. If you are wanting to pay cash for your sessions, we are happy to take a card number just as security but not process it.

5. All follow up appointments require 48 hours notice to change or cancel or full fee will be charged (again, extenuating circumstances may be considered).

6. We thank you for your understanding and cooperation and are excited to share in your experience of becoming the happy, empowered, authentic person you are born to be.

I accept the terms and conditions stated above