book - Shiatsu Massage and Transpersonal Therapy in SELBY with Valeria

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home
valeria
sessions
testimonials
book

getting to know you

To book a session, please submit this form and I'll get back to you in 1 or 2 days.

Please give yourself at least 20 minutes. Not all questions are mandatory, but all are encouraged.

Contact Details

* Indicates required field

Full Name *

First

Last

Phone *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

DOB *

Emergency Contact & Phone *

Main Occupation *

History

Main reason for contact, presenting issues *

All past surgeries, major illnesses & accidents *

Current and past medication, supplements or drugs *

Any significant family history of mental or physical disease *

Any relevant life history that you feel may be impacting your current health *

(For women) Frequency of menstruation, any significant pain, discomfort, moods, symptoms or patterns related to cycle *

Current self care (exercise, diet, spiritual practices, therapies) *

Current state of emotional health (quality & patterns of moods, significant stress, etc) *

Current state of sexual & reproductive health *

Describe your energy levels - be creative *

Quality of sleep (check all that apply) *

Very poor Irregular Average Oversleep /fatigued slee Good/ Regular Wake up tired frequently

Current quality of digestion (check all that apply) *

Regular Painful Bloating Constipation Loose/ urgency

Bonus round: What is something that's really important to you? *

Outcomes: how would you like to feel after a session? *

Submit

Selby clinic room

0409 011 490

MON - SAT 12pm - 6pm
by appointment only