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Guided Bloom

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Name: *

First

Last

Date of Birth & Current Age: *

First

Last

Contact Number: *

Email: *

Location: *

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

What are your main challenges that have brought you here?

What is your main goal/outcome you're wanting to achieve?

Please select all that you feel STRONGLY apply:

Other 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 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.

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. Your trained practitioner Klara (Guided Bloom) offers EFT and Matrix Reimprinting sessions only. 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 agree to share with Klara (Guided Bloom) all issues on which the client needs assistance, and that issues not shared with the practitioner may not be resolved or may impede the successful achievement of the clients goals and objectives. The practitioner Klara (Guided Bloom) agrees to use her best efforts to assist the client to resolve issues. I understand that all information I share with Klara (Guided Bloom) is confidential and any information will not be released unless legally required.

Consent & Agreement: *

I understand and agree

This agreement is entered into by and between the client and practitioner Klara (Guided Bloom). This client will be under the 1-on-1 program 'From Head to Heart' for 8 sessions. The client understands that it is not possible to withdraw from the program. The client agrees to pay before the sessions take place. The client agrees 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 and tasks 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: *

Name: *

First

Last

Date of Birth & Current Age: *

First

Last

Contact Number: *

Email: *

Location: *

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

What are your main challenges that have brought you here?

What is your main goal/outcome you're wanting to achieve?

Please select all that you feel STRONGLY apply:

Other 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 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.

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. Your trained practitioner Klara (Guided Bloom) offers EFT and Matrix Reimprinting sessions only. 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 agree to share with Klara (Guided Bloom) all issues on which the client needs assistance, and that issues not shared with the practitioner may not be resolved or may impede the successful achievement of the clients goals and objectives. The practitioner Klara (Guided Bloom) agrees to use her best efforts to assist the client to resolve issues. I understand that all information I share with Klara (Guided Bloom) is confidential and any information will not be released unless legally required.

Consent & Agreement: *

I understand and agree

This agreement is entered into by and between the client and practitioner Klara (Guided Bloom). This client will be under the 1-on-1 program 'From Head to Heart' for 8 sessions. The client understands that it is not possible to withdraw from the program. The client agrees to pay before the sessions take place. The client agrees 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 and tasks 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

From Overthinking to Overcoming:
Guiding Women through Effortless Change

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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