Confidential Client Intake Form

Personal Details

Name

First Last

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone

Email

Enter Email Confirm Email

Date of birth

Current age

Occupation (now or former)

Partners name

First Last

Marital status

Do you or your partner have any children or dependants?

Yes
No

Medical or Other Practitioners

GP name and surgery

List any other therapists/therapies that you use

Current medication

Supplements or remedies that you are currently taking

Do you smoke? (How many? If stopped, when?)

Alcohol (How much?)

Have you ever had any kind of substance abuse/addiction?

Allergies (specific allergen and reaction)

Surgical history or recent procedures (year and type)

Accidents or traumas

Any counselling or treatment in the past

Do you know anything about your own birth or early days?

Any continuations or extra information:

Please read the Terms and Conditions which will open in a new page.

I agree to the Terms and Conditions

Thank you for taking the time to fill in any of this form. If any of the questions have triggered an unwanted response before your appointment, please get in touch. By filling it in, you are giving me permission to work with you. If any in doubt, contact your GP.

Message Jay: glowfertility@gmail.com

Mobile: 07725035047 (sometimes it is not possible to take calls, so emails are preferable)

Skype clients: glowfertility

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Personal Details

Medical or Other Practitioners

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