New Client Information Form Name * First Name Last Name Email * GP Name and Address * In case of emergency contact (Name, Relationship to you, Phone Number) * Do you have any current or historic medical conditions or any physical or mental health issues that you have been diagnosed with? * Yes No If Yes, please describe. Are you currently taking any medication? * Yes No If Yes, please describe. Do you have any allergies or phobias? Yes No If Yes, please describe Do you have any physical pain or injuries? Yes No If Yes, please describe. What is the main reason/s you are seeking Shamanic healing, Counselling or Reiki? Where did you hear about this service? Would you like to be added to the mailing list? (Newsletters are infrequent and you can unsubscribe at anytime) Yes No Consent I give consent to receiving therapy from Aisha Amarfio. I understand there is no guarantee of success in the treatment of my issue. I further understand that Shamanic Healing, Counselling or Reiki should not be construed as a substitute for medical care for any physical or psychological ailment. I understand that Shamanic Healing, Counselling or Reiki can complement any medical or psychological care. I understand that Shamanic Healers are not qualified to diagnose or prescribe medical treatment for any physical or psychological issue. I confirm that I have stated all my known medical conditions and answered all questions honestly. Alcohol and recreational drugs I understand that for full benefit of the session, it is advised to refrain from drinking alcohol or taking recreational drugs within 24hours of the appointment. Cancellation Policy I understand that in any event where I need to cancel or change my appointment, a minimum of 24 hours notice must be given. A cancellation fee will apply if changes are made with less than 24 hours notice. (£35 London) Confidentiality and General Data Protection Regulation Aisha Amarfio offers a confidential service. The information you give will remain confidential and not be discussed, shared or passed on to any third party, without your express permission, except in exceptional circumstances, where there are concerns that either yourself or someone else is suffering, or at risk of significant harm. In order to offer you a professional service Aisha Amarfio needs to keep relevant records of your contact details and these are kept in accordance with the General Data Protection Regulation 2018. I consent to the terms above Thank you!
