Splankna New Client Form - Well of Life Center for Holistic Healthcare

CLIENT INFORMATION

Name *

First

Last

Email *

Main Phone Number *

Secondary Phone Number

Age *

Gender *

Religious Preference *

MARITAL HISTORY

Marital Status *

1st Marriage:

Date(s):

Spouse:

Children:

Who has custody of your minor children?

2nd Marriage:

Date(s):

Spouse:

Children:

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.

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.

Splankna Therapy New Client Form