Please copy and paste this form into a Word Document so that you can complete it. Please then print it out, sign it and post it to Personal Power Development, Old Castle, Llangain, Carmarthen SA33 5BD.
Name:
Address:
Telephone Number:
Email:
Skype:
Messenger:
Year of Birth:
Marital Status:
Children:
GENERAL CONCERNS:
WHAT YOU WOULD LIKE TO ADDRESS:
MEDICAL HISTORY (where relevant):
STRESS-RELATED/PSYCHOLOGICAL/EMOTIONAL HISTORY:
ISSUES:
DOMESTIC SITUATION:
HEALTH GENERALLY:
ARTIFICIAL AIDS e.g. Pacemaker:
MEDICATION & REASON FOR IT BEING PRESCRIBED
ALLERGIES
PHOBIAS OR FEARS:
DO YOU SUFFER FROM: Migraine, Epilepsy, Heart Problems, Breathing Problems, Nervous Conditions, Othe
I enclose a cheque payable to Angela Timms or I have sent a payment via paypal to serenitywildhare@yahoo.com for my initial set up fee together with …………………….. as start up credit to pay for my one on one training.
Signed Date Print Name
