Guided Bloom

In Take Form & Agreement

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This questionnaire will set us up for success during our time together.
You can be as brief or as detailed as you like.
Name:
Date of Birth & Current Age:
For timezone purposes
Emergency Contact Details:
Do you have a history of:
Are you currently feeling suicidal?
Do you have a history or current issues with substance abuse?
Selected Value: 0
Selected Value: 0
Please select all that you feel STRONGLY apply:
Please select all that you feel apply:
How committed are you to achieving your outcome/goal?
Have you done EFT or Matrix Reimprinting before?
Cancellation Policy:
I understand that if I need to cancel or change my appointment out of courtesy I will give at least 24 hours notice in advance or the session may be forfeited.
Consent & Agreement:
I understand that Klara (Guided Bloom) is not providing psychological or medical advice and that working together should in no way replace sound treatment from a licensed healthcare provider. I understand that all information I share with Klara (Guided Bloom) is confidential and any information will not be released unless legally required. I understand that outcomes cannot be guaranteed in any way. I agree to release Klara (Guided Bloom) from all liabilities and claims for any causes, past, present and future.
Consent & Agreement:
I understand that it is not possible to withdraw from the program. I agree to complete any due payments before sessions take place. I understand that no refunds will be issued.
Consent & Agreement:
I agree to take complete responsibility for my own comfort, health and well-being while working with Klara (Guided Bloom). I understand that the results will depend on taking action and following the advice, tasks, techniques and strategies of the practitioner to the best of my ability. I understand that the practitioner Klara (Guided Bloom) can only facilitate and that I must take full responsibility for making the process work and that no one can do that for me.
I agree that typing my name above is the electronic equivalent of my actual signature.

This questionnaire will set us up for success during our time together.
You can be as brief or as detailed as you like.
Name:
Date of Birth & Current Age:
For timezone purposes
Emergency Contact Details:
Do you have a history of:
Are you currently feeling suicidal?
Do you have a history or current issues with substance abuse?
Selected Value: 0
Selected Value: 0
Please select all that you feel STRONGLY apply:
Please select all that you feel apply:
How committed are you to achieving your outcome/goal?
Have you done EFT or Matrix Reimprinting before?
Cancellation Policy:
I understand that if I need to cancel or change my appointment out of courtesy I will give at least 24 hours notice in advance or the session may be forfeited.
Consent & Agreement:
I understand that Klara (Guided Bloom) is not providing psychological or medical advice and that working together should in no way replace sound treatment from a licensed healthcare provider. I understand that all information I share with Klara (Guided Bloom) is confidential and any information will not be released unless legally required. I understand that outcomes cannot be guaranteed in any way. I agree to release Klara (Guided Bloom) from all liabilities and claims for any causes, past, present and future.
Consent & Agreement:
I understand that it is not possible to withdraw from the program. I agree to complete any due payments before sessions take place. I understand that no refunds will be issued.
Consent & Agreement:
I agree to take complete responsibility for my own comfort, health and well-being while working with Klara (Guided Bloom). I understand that the results will depend on taking action and following the advice, tasks, techniques and strategies of the practitioner to the best of my ability. I understand that the practitioner Klara (Guided Bloom) can only facilitate and that I must take full responsibility for making the process work and that no one can do that for me.
I agree that typing my name above is the electronic equivalent of my actual signature.

Modern Mindful Therapy

Guided Bloom

Guiding Women from Overthinking to
Confidently Leading from the Heart

I acknowledge the Traditional Owners of the land where I work and live, the Wurundjeri People, and pay my respects to Elders past, present and emerging.

Locations

Online World Wide

80 Paisley St Footscray, Melbourne

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Contact

hello@guidedbloom.com

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