Suitability Evaluation Form
B.E.M.E™ Therapy & Coaching commence by first filling in a pre-consultation form to see if your complaint or request qualifies for the therapy/coaching. After the pre-consultation form is read, you will be contacted for either a consultation to be scheduled or you will be informed of the suitability for therapy/coaching.
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Email *
Salutation (Dr/Mr/Mrs/Ms etc) *
Name *
Contact
Gender *
Age Group *
Which route are you considering to embark on? *
Please check what you are experiencing below (can tick more than 1): *
Required
Background of your complaint including any diagnosis (how long has it been? / how was it incurred? / diagnosis? / seen who for help so far? / other information even from childhood or past?) *
What is it you would like to do most but your above pain(s) is restricting you currently? *
What would you consider to be realistically successful in this course of therapy/coaching? *
Do you agree to help yourself in every way to improve your condition? *
Do you need assistance in moving around?
Clear selection
Is there other existing disabilities (e.g. Hearing issues...)
Do you have other medical conditions?
Other info that you might like to add/inform? *
In case of emergency, please contact: *
Number *
Relationship *
Indemnity: Danspire International and her trainers/therapists strive to ensure that all safety precautions are taken prior to and during an event/class. However, I indemnify Danspire International, organizers, affiliates, teachers and studio owners against any accidents , injuries, damage, or loss including death that might arise from taking part in the event/class or being on the premises during  the event/class.
Footage Release: For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of myself, the recording of my voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for this session for my own learning and growth. Unless approved by me, Danspire will not use the footage for education purpose. I understand that the term "photograph" as used herein encompasses both still photographs and motion picture footages. I hereby release Vincent Yong and Danspire International and premise from all claims of every kind on account of such use.
To commence therapy, the above is necessary to help and assist you.
I agree fully to the above. *
Required
Upon submitting this form, I deem to have read and understood the content and hereby agree to participate in Vincent's B.E.M.E™ Therapy/Coaching.
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