Golden Light Healing Client Health & Wellbeing Form

Please complete this form before your treatment so Becky can support you safely and comfortably.

You can use it to share any health notes, treatment goals, preferences, sensitivities, mobility needs, or anything else you feel may help your session feel calm and suitable for you.

If you would rather speak to Becky directly, please contact her on 07903 111956.

Name

Date of Birth

Phone Number

Email

Emergency Contact Name and Number

Date Completed

What would you like complimentary support with today?

Is there anything else you would like Becky to know before your session?

Are you currently under the care of a GP, consultant, therapist, counsellor, or other health professional?

If yes, please give brief details if you're comfortable doing so.

Brief health and medical care details

Physical wellbeing: please tick anything that currently applies

Other physical wellbeing notes

Emotional wellbeing: please tick anything that currently applies

Other emotional wellbeing notes

Is there anything that may help you feel more comfortable during your session?

Quiet space

Gentle lighting

No strong scents

No-touch energy healing preferred

Time to pause and ask questions

Minimal talking during treatment

More talking and reassurance

Other

Please share any preferences, needs, or adjustments that may help you feel comfortable during your treatment

Do you have any skin concerns, conditions, allergies, or sensitivities Becky should be aware of?

Yes, skin concern or condition

Yes, allergy or sensitivity

Yes both

Not sure

If yes, please give brief details:

Consent for treatment: please tick to confirm

I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that Golden Light Healing offers complementary wellbeing services and does not diagnose or treat or cure medical conditions.

I understand that I can ask questions before, during, or after my session and can stop at any time.

I agree to tell Becky about any health changes that may affect future sessions.

I consent to Golden Light Healing storing this completed form securely for 12 months.

Privacy policy and healing statement:

https://www.beckygoldenlight.co.uk/privacy-policy

I confirm I have read and understood the privacy policy and healing statement.

Yes

Golden Light Healing | Private and confidential client wellbeing form 🌿