Splankna Therapy New Client Form

CLIENT INFORMATION

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Main Phone Number

Secondary Phone Number

Age

Gender

Religious Preference

Who will you be seeing for your Splankna session?

MARITAL HISTORY

Marital Status

1st Marriage:

Date(s):

Spouse:

Children from marriage and how many:

Who has custody of your minor children?

2nd Marriage:

Date(s):

Spouse:

Children from marriage and how many:

Who has custody of your minor children?

Other Marriages/Children:

List any other marriages and/or children:

HEALTH INFORMATION

Have you ever considered suicide?

Yes
No

Have you ever attempted suicide?

Yes
No

Do you suffer from:

Migraines
Epilepsy
Vertigo

Check any of the following which are currently causing you difficulty:

What is/was your Father’s main character weakness?

What is/was your Mother's main character weakness?

What is your birth order? (i.e. oldest, youngest, of how many, etc.)

How will you be different if this therapy is successful?

CLIENT CONSENT

Please check below to indicate that you have read and understand the Statement of Confidentiality below:

I understand and agree to the below Statement of Confidentiality.

Statement Of Confidentiality:

The Client-Therapist relationship offers confidentiality in so far as allowed by the laws of the State of Pennsylvania. Under certain conditions, the right to confidentiality is necessarily violated. Those conditions include the potential for suicide or homicide on the part of the client. Likewise, when there is reason to suspect that physical or sexual abuse has occurred to a child or an elderly person, the therapist is required by law to report the situation to the Department of Human Services, division of Child Protective Services.

SIGN BY TYPING YOUR NAME BELOW TO ATTEST TO THE FOLLOWING: I have read, acknowledged, and agree to the Client Informed Consent and Disclosure Statement:

Please click HERE to read our Client Informed Consent and Disclosure Statement. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Consent and Disclosure Statement.

WELLNESS SERVICES

Please note…

CLIENT INFORMATION

MARITAL HISTORY

1st Marriage:

2nd Marriage:

Other Marriages/Children:

HEALTH INFORMATION

CLIENT CONSENT

Contact Us

Hours

Well of Life Center for Holistic Healthcare

Pin It on Pinterest