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Guided Bloom

In Take Form & Agreement

This questionnaire will set us up for success during our time together. You can be as brief or as detailed as you like.

Name: *

First

Last

Date of Birth & Current Age: *

First

Last

Contact Number: *

Email: *

Location: *

For timezone purposes

Emergency Contact Details: *

First

Last

Occupation:

Do you have a history of: *

Seizures
Anaphylactic Shock
Psychiatric Issues
Attempted Suicide
Panic Attacks
Severe Depression
Other
None of the above

Other medical issues I should know about?

Are you currently feeling suicidal? *

Yes
No

Do you have a history or current issues with substance abuse? *

Yes
No

If you could change one thing in your life in the next 3-6 months, what would that be? *

This will be our primary goal and our main focus during our time together

How much is this particular challenge impacting your life right now out of 100%? *

With 100% being it's impacting you every single day and stopping you from living the life you want

How possible does it feel right now that you can actually change/heal from this struggle out of 100%? *

With 100% being certain you can change it

What else would you like to change (either add or subtract) from your life? *

These will be our secondary goals during our time together. Everything traces back to the same beliefs so you will see changes in multiple areas of your life.

Is there anything else important you'd love for me to know before we start?

Please select all that you feel STRONGLY apply:

Other(s) not mentioned above:

Please select all that you feel apply:

Anxiety
Depression
Self Worth/Esteem
Stress
Overwhelm
Physical Pain
Illness
Habits/Addictions
Fears
Phobias
Allergies
Relationships
Procrastination
Perfectionism
Prosperity/Success Issues
Weight Issues
Grief/Loss
Anger/Frustration
Lack of Joy/Purpose
Traumatic Memories
Other

Other(s) not mentioned above:

How committed are you to achieving your outcome/goal? *

1
2
3
4
5
6
7
8
9
10

Have you done EFT or Matrix Reimprinting before?

Yes
No

How did you hear about Guided Bloom?

Cancellation Policy: *

I understand and agree

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 and agree

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 and agree

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 understand and agree

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.

Sign: *

I agree that typing my name above is the electronic equivalent of my actual signature.

Date: *

This questionnaire will set us up for success during our time together. You can be as brief or as detailed as you like.

Name: *

First

Last

Date of Birth & Current Age: *

First

Last

Contact Number: *

Email: *

Location: *

For timezone purposes

Emergency Contact Details: *

First

Last

Occupation:

Do you have a history of: *

Seizures
Anaphylactic Shock
Psychiatric Issues
Attempted Suicide
Panic Attacks
Severe Depression
Other
None of the above

Other medical issues I should know about?

Are you currently feeling suicidal? *

Yes
No

Do you have a history or current issues with substance abuse? *

Yes
No

If you could change one thing in your life in the next 3-6 months, what would that be? *

This will be our primary goal and our main focus during our time together

How much is this particular challenge impacting your life right now out of 100%? *

With 100% being it's impacting you every single day and stopping you from living the life you want

How possible does it feel right now that you can actually change/heal from this struggle out of 100%? *

With 100% being certain you can change it

What else would you like to change (either add or subtract) from your life? *

These will be our secondary goals during our time together. Everything traces back to the same beliefs so you will see changes in multiple areas of your life.

Is there anything else important you'd love for me to know before we start?

Please select all that you feel STRONGLY apply:

Other(s) not mentioned above:

Please select all that you feel apply:

Anxiety
Depression
Self Worth/Esteem
Stress
Overwhelm
Physical Pain
Illness
Habits/Addictions
Fears
Phobias
Allergies
Relationships
Procrastination
Perfectionism
Prosperity/Success Issues
Weight Issues
Grief/Loss
Anger/Frustration
Lack of Joy/Purpose
Traumatic Memories
Other

Other(s) not mentioned above:

How committed are you to achieving your outcome/goal? *

1
2
3
4
5
6
7
8
9
10

Have you done EFT or Matrix Reimprinting before?

Yes
No

How did you hear about Guided Bloom?

Cancellation Policy: *

I understand and agree

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 and agree

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 and agree

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 understand and agree

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.

Sign: *

I agree that typing my name above is the electronic equivalent of my actual signature.

Date: *

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

Contact

hello@guidedbloom.com

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