CLIENT INTAKE
&
HEALTH QUESTIONNAIRE

Before we can confirm your booking, we require all clients to complete and return our Client Intake and Questionnaire Form. This helps us understand your needs, ensure your comfort, and assess any relevant health considerations. We cannot proceed with your booking until the completed forms have been received and reviewed by our team. Please fill them out carefully and return them to us as soon as possible to secure your session.

Client Intake & Health Questionnaire

Personal Details

First name

Last name

Birthday

Day

Month

Year

Phone

Address

Emergency Contact

Emergency contact full name

Emergency contact relationship

Emergency contact

Health Information

Are you currently taking any medications?

Yes

If yes, please list.

Have you had any recent surgeries?

Yes

If yes, please describe.

Do you have a history of photo sensitivity or reactions to flashing lights?

Yes

If yes, please describe.

Session Goals

What is your primary reason for visiting Energy Within, or what do you hope to achieve from your session(s)?

Declaration & Signature

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that it is my responsibility to inform EnergyWithin of any changes to my health before future sessions.

Signature

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Date

Day

Month

Year

Consent & Liability Waiver

IMPORTANT: PLEASE READ CAREFULLY BEFORE SIGNING

This form is intended to ensure that you fully understand the nature of the services offered by Energy Within and to confirm your voluntary participation. Your safety, well-being, and informed consent are our priority.

Nature of the service

Energy Within offers sessions involving light, sound, sacred geometry, and frequency-based technology using the Unifyd Light System. These sessions are intended to promote relaxation, inner balance, and energetic harmony.

Please note:

This service is non-medical, non-diagnostic, and not a substitute for medical treatment or professional healthcare.
No medical claims are made or implied.
You should consult your GP or healthcare provider before participating if you have any medical conditions or concerns.

Potential Risks & Reactions

Although most individuals experience only relaxation and calm, some may experience temporary side effects, including but not limited to:

Mild dizziness or light-headedness
Emotional release or fatigue
Disorientation
Photosensitive responses (e.g., in individuals with epilepsy or light sensitivity)

If you have epilepsy, a pacemaker, or other contraindications, you must inform the facilitator before your session.

Voluntary Participation

I acknowledge that my participation in Energy Within sessions is entirely voluntary, and I may discontinue the session at any time. I understand that I am responsible for my own health and well-being during and after the session.

Health Responsibility

I agree to inform Energy Within of any changes to my physical or mental health that may affect my ability to participate safely in future sessions.

Liability waiver

By signing this form, I acknowledge and accept all potential risks associated with the services provided. I voluntarily waive and release Energy Within, its owners, employees, and affiliates from any and all liability, claims, demands, or causes of action arising from participation in any session.

Client declaration

I confirm that:

I have read and understood the above information

I have had the opportunity to ask questions and receive answers

I am participating of my own free will

I understand and accept the risks

I agree to the terms outlined in this waiver

Full name

Date

Day

Month

Year

Signature

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Informed Consent Form

Welcome to Energy Within. Our mission is to offer a safe and supportive environment where individuals can explore natural energy-balancing experiences using advanced wellness technology.

Please read the following information carefully before proceeding with your session.

Session overview

During your session at Energy Within, you will be invited to sit or recline in a peaceful space while experiencing a combination of:

Light frequencies (delivered via the Unifyd Light System)
Sound therapy
Sacred geometry visuals and vibrational resonance
Subtle energy stimulation intended to support relaxation and inner balance

These sessions are designed to promote calmness, clarity, emotional alignment, and energetic well-being.

important disclaimers

This session is non-medical and does not replace professional healthcare.
No diagnoses or treatments are offered.
The experience and outcomes may vary for each individual. Some may feel deeply relaxed or energized, while others may notice little to no immediate effect.
The benefits are not guaranteed, and ongoing results may require multiple sessions and/or lifestyle support.

your rights & responsibilities

You may ask questions at any time before, during, or after the session.

You may stop the session at any time, for any reason, without explanation.
Please notify your facilitator immediately if you feel unwell or uncomfortable at any point.
You are responsible for informing us of any medical conditions or changes to your health status.

Client Declaration

Client Declaration

I understand the nature of the session and the technology used.

I acknowledge that this session is not a substitute for medical or psychological care.

I have had the opportunity to ask questions and they have been answered to my satisfaction.

I voluntarily consent to participate in a session at Energy Within.

I understand that results may vary and benefits are not guaranteed.

I know I may stop the session at any time.

Full name

Date

Day

Month

Year

Signature

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Privacy & Data Protection Consent (GDPR)

At EnergyWithin, your privacy is important to us. This form outlines how we collect, use, and store your personal and health information in compliance with the UK General Data Protection Regulation (GDPR).

Please read the information below and sign to confirm your understanding and consent.

What Data We Collect

We collect and store the following types of information for the purpose of providing our services safely and effectively:

Full name, contact details, and emergency contact
Date of birth and basic demographic details
Relevant health information (e.g. medical history, medication, contraindications)
Session history and feedback
Consent and waiver documentation

Why We Collect This Data

Your information is collected to:

Assess suitability for our sessions
Ensure your safety and well-being
Maintain accurate records for insurance and regulatory purposes
Improve the quality of our services
(Optional) Provide you with occasional updates, promotions, or wellness tips if you opt-in

How We Store and Protect Your Data

Data is stored securely in physical and/or encrypted digital formats
Only authorised personnel (e.g., the business owner or facilitator) have access
Records are retained for up to 7 years, as recommended for complementary and wellness services, unless otherwise required
After this period, your data will be safely deleted or destroyed
We do not sell or share your personal data with third parties without your explicit consent, except where required by law

Your Rights

Under the UK GDPR, you have the right to:

Access the data we hold about you
Request corrections or updates
Withdraw your consent at any time
Request deletion of your data (where legally permissible)

To exercise your rights, contact:📧 energywithinenquiries@gmail.com

EnergyWithin, TipsgroveFarm, Ledbury, Herefordshire. HR8 2RW

Marketing Preferences (Optional)

Would you like to receive occasional emails about promotions, wellness tips, or updates from Energy Within?

Yes

Client declaration

I have read and understood how my data will be collected, used, and stored.

I give my informed consent for EnergyWithin to collect and retain my personal and health data for the purposes stated.

I understand I can withdraw consent at any time.

Full name

Date

Day

Month

Year

Signature

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