Client Consultation Youth Please complete the following form in as much detail as possible. This will help us on our journey together. If you are not willing or not able to complete a section at this time, please just enter an ‘x’ for now, so your form will be submitted. Client Consultation Record - Youth Surname*Given Name/s*Email* Your AgeDate of Birth* Health Insurance Fund (If Any)Residential / Postal Address*Suburb*Postcode*Mobile Phone*Home Phone*If you only have a mobile phone please enter your mobile number Parent / Guardian 1Name*MobileEmail* RelationshipOther Contact Number Parent / Guardian 2Name*MobileEmail* RelationshipOther Contact Number About YouBirth Order - You are*Please Choose1st2nd3rdOtherYour Brothers & Sisters: Names and current age*Growing up background including key events* Psychological StressHave you ever experienced, or undertaken treatment for, psychological conditions such as depression, anxiety etc?*Please ChooseYesNo Illness and Injury3>Major diseases/illnesses (include year if known)*Please enter N/A or Nil if nothing to addOperationsPlease enter N/A or Nil if nothing to addAccidentsPlease enter N/A or Nil if nothing to addOtherPlease enter N/A or Nil if nothing to add LifestyleDrugs taken: (current & past, include smoking)*Please enter N/A or Nil if nothing to addSleep patterns or difficulties*Please enter N/A or Nil if nothing to addExercise Type & Frequency*Please enter N/A or Nil if nothing to addEnergy Level*(No Energy=)0 1 2 3 4 5 6 7 8 9 10(= Maximum)Please Choose12345678910Supplements/Vitamins*Please enter N/A or Nil if nothing to addFood Preferences/Cravings*Please enter N/A or Nil if nothing to addSensitivities/Allergies*Please enter N/A or Nil if nothing to addHobbies & Interests* Why have you booked? Please answer the following questions. There are no “right” or “wrong” answers. If you do not understand a question, or do not have an answer, please leave and discuss at your consultation.How much stress do you feel you are experiencing in your life?*(No stress=) 0 1 2 3 4 5 6 7 8 9 10 (= Maximum)Please Choose12345678910What issue/s have you come to resolve?*How does this issue express itself in your life?*Please Choose as many as appropriate Physical symptoms Learning difficulties Interpersonal conflict Interpersonal difficulties Low energy levels Phobias Other Anything else about how this issue expresses itself in your life?What would you like to be different in your life?*How will you know that you have achieved this?* How much pain do you feel you are experiencing in your life, in the following areas? (No pain=) 0 1 2 3 4 5 6 7 8 9 10 (= Maximum)Physical Pain?*Please Choose12345678910Emotional Pain?*Please Choose12345678910Mental Pain?*Please Choose12345678910Are you undertaking any other treatments ?*Please ChooseYesNoWhat techniques do these other treatments involve?Please choose any that apply Chiropractic Reflexology Kinesiology Shiatsu Reiki Naturopathy Herbs Massage Treatment by a General Practitioner Physiotherapy Psychology Psychiatry Other Please specify 'other' treatmentWhat is most important for you in our work together?*How did you hear about EWC?*Please ChooseGoogle SearchWord of MouthA Friend/ColleagueName of your Friend/Colleague?EmailThis field is for validation purposes and should be left unchanged.