Energy Healing Assessment
Healing treatment is currently from Lulu, Co-Creator with Source of Nature Spirits UK and Wee Nature Spirits outdoor playgroup. Should Lulu become fully booked over time, another Energy Healing Practitioner will be recommended.
Email *
Name *
Where do you live? I have to charge £1 extra per mile if further than 7 miles from Chobham. *
Date / Year of Birth *
What is your reason for seeking energy healing? *
Required
Have you had an energy healing treatment before? *
If Yes to having an energy healing treatment before, what was it, your brief experience and when? You can skip this.
How did you hear about Lulu's energy healing? *
How would you rate your general state of health? *
How would you rate your stress levels? *
Low
High
How would you rate your sleep pattern? *
Very good
Poor
How often do you feel fatigued? *
Rarely
All the time
How do you rate your ability to relax? *
Very good
Poor
Do you meditate? *
Do you have children? *
How would you rate your general sense of happiness? *
Mostly happy and positive
Mostly low and sad
How would you rate your diet? *
Very healthy
Not healthy at all
How much water do you drink per day? *
Optional Extra info:
2 litres
Only in teas
Are you pregnant? *
Optional Extra info:
Unfortunately I am unable to treat anyone who may be pregnant, has a pace maker or undergoing chemotherapy. Put n/a if this does not apply to you. *
Please tick any issues that apply: *
Required
Are you currently under Doctors care for a specific reason? *
Are you taking any medication? *
Details of medication & diagnosis
List any previous major illnesses, accidents, surgeries or broken bones. *
Please state any areas of physical pain or discomfort at present *
Are you hypersensitive to sound/light? *
Are you hypersensitive to sage/palo santo/ incense smoke? *
Any other relevant information, such as family history, traumas, counselling etc please share here or put n/a. This is so I can plan your session in the best way possible. *
I currently offer sessions in your home. It's better if we are alone eg no children/pets. We can also go outdoors into nature. Your choice. *
Name of Next of Kin *
Next of Kin Telephone Number (please double check) *
Please see website for any further information on what to expect during and after a treatment before reading and signing the following client declaration.
Client Declaration
By signing this form I give my consent to the healing and acknowledge I have read and understood the information below.

I declare that the information I have given is correct and that as far as I am aware I can undertake treatment without adverse effects. I have checked with my GP if on any medication/ treatments.

I must communicate any levels of discomfort during the treatment session.

I have fully read about on what to expect during and after a treatment on Nature Spirits UK website and I am willing to proceed. I understand that any complementary therapy treatment does not substitute medical treatment.

I hereby indemnify Louise Beattie (aka Lulu) of Nature Spirits UK against all adverse reactions or side effects sustained as a result of a treatment.

PRIVACY STATEMENT
The information you provide on this form is collected by Nature Spirits UK (NSUK) as the data controller on the basis of your consent to enable you to receive an Energy Healing Treatment.
Your personal information will be processed in line with the Data Protection Act 2018 and the General Data Protection Regulation (GDPR). It will not be disclosed to third parties for marketing purposes.
NSUK will only share your information with third party organisations on a lawful basis - for example, should a medical emergency arise.
NSUK will continue to hold your personal data on file for as long as you continue to receive treatments.
Any personal data held will be destroyed after two years of inactivity.
Your data is not processed for any further purposes other than those detailed in this statement.
If you chose to not share your personal data with Nature Spirits UK, then treatment will NOT be possible.

Client Signature (PRINT NAME) *
Date *
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