Birthday*

Consent to Contact Emergency Contact*

Children*

If so, do you consent to your GP being contacted?*

If so, do you consent to them being contacted if required?*

Do you experience or have you been diagnosed with any of the following?*

Are there any behaviours, substances, or habits that you feel are difficult to control or that are having a negative impact on your life?*

If yes, please indicate any areas that apply (tick all that apply)

By submitting this form, you confirm you’ve read, understood and agree to Terra Soul Therapies’ Consent and Confidentiality Policy. You acknowledge your right to discuss or withdraw consent at any time, except where required by law (as per AHPRA & PACFA)*

Please confirm that you have reviewed the fees information and consent to payment of the applicable fees*

Cancellation Policy: Please provide at least 24 hours’notice to cancel or reschedule. Sessions cancelled within 24 hours require full payment, except in genuine or unforeseen circumstances.*