Name: Wholelistic Wellbeing | Transformation Coaching USA
Telephone: +18137898377
Price range: $

STATEMENT OF PSYCHOLOGICAL AND HEALTH CONDITION
All information provided on this form is kept confidential.
Name
Age
Sex:
- Male
- Female
Telephone:
Please initial after each item and then sign below:
1 : Please list any physical disabilities, allergies, conditions, past injuries or any limitations that could limit your participation on the journey:
2 : What medications are you taking or will you take during the journey? Please list any precautions and side effects.
3 : Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological conditions?
4 : Do you have a history of sexual or physical abuse? Do you have a history of substance abuse? Do you have a history of suicidal tendencies or a suicide attempt?
5 : If I should warrant immediate medical attention on this journey, I hereby grant permission to the medical personnel, selected by the journey guides, to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted.
6 : If I should warrant immediate medical attention on this journey, I hereby grant permission to the medical personnel, selected by the journey guides to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.
7 : If I should warrant immediate medical attention on this journey, I hereby grant permission to the physician selected by (YOUR NAME) and representatives to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me.
8 : I agree to adhere to the decision by Donna Sharpe, Wholelistic Wellbeing, and representatives, regarding the suitability of my participation in the excursion.
9 : I declare these statement is correct to the best of my knowledge.
Participant's signature
Date
MM slash DD slash YYYY

Donna has captivated many individuals over the years as a Speaker | Inner Healing Coach | Facilitator. Her healing gifts and lessons of how to live a holistic life of vitality have been positively received and implemented by many clients over the years.