Thank you for your booking. Please complete the following questionnaire prior to your session.

All information provided is confidential and will assist us in supporting you and your goals. We may contact you using the details provided for administration purposes of this session and any further sessions booked.

Please note that for Chi sessions, advice and support is given using an Eastern understanding of Chi energy and the effect it has on an individual’s health and wellbeing. We provide this support and guidance but cannot make any guarantees as to an individual’s progress. We advise speaking to your GP regarding any current medical conditions.

Please contact us on 01305 564 088 or via email at contact@thechizone.com should you have any further questions.

We look forward to seeing you soon.

Prefix

Preferred Prefix

First Name

Last Name

Prefered Name / Nickname

Email

Telephone Number

Date of Birth

Date of Birth - old dropdown box

Gender

Preferred Gender

Are you pregnant?

Yes

No

Not sure

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Retired?

Yes

No

Occupation

How did you hear about us?

Please check the boxes below if you are connected to any of these organisations

MS Society Dorset

Dorset County Council

	Please select
Member of MS Society Dorset
Carer
Volunteer
Other

Session details

Therapist

Incheol Ha

Françoise Ha

Not sure

Date and Time of Appointment

Date/Time of session old dropdown box

How is your health?

Further details

Please include any additional details you wish to provide about your physical and emotional wellbeing that have not been mentioned already

Please detail any current diet, exercise or treatment plans

What are your reasons for booking this session?

What would you like to achieve for your health for the future?

Additional comments

I agree to the booking policy. Read more at https://thechizone.com/terms/

Yes

I consent to The Chi Zone storing my submitted information for client administration purposes. More details at https://thechizone.com/privacy-policy/

Would you like to receive The Chi Zone email newsletter including updates and offers?

Yes

No

01305 564 088

0330 1331 034

hello@thechizone.com

Your longer-term health plan

Send us a message

Tel: (01305) 564 088

or 0330 1331 034

hello@thechizone.com