Name

First Name

Last Name

How did you hear about this?

Date of Birth

Address

Telephone Number

Emergency Contact Details/Next of Kin

Is a doctor treating you

Yes

List your challenges in order of priority i.e Physical, emotional, mental, financial, fears, phobias, addictions etc

Any potential life threatening conditions? i.e. heart trouble

List any medications and supplements that you are taking? If you were on long term medication in the past, please include it in your answer. Include your alcohol and daily intake of water?

Have you ever been diagnosed with Bipolar?

Yes

Do you agree to the terms and conditions?

Terms and conditions are available to read on Theta page

Yes