CASE STUDY SUBMISSION FORM

NAME Mr Mrs Miss
ADDRESS

CONTACT DETAILS

Name of Client/Patient/Student

                                                       AGE………….   SEX……… Which Clinic did you attend    The Chi Clinic Other
Which class or course of classes. Who was the therapist or teacher:-Tony Hardiman, Vicky Ahern, Other…………..

How did you find the Clinic….On recommendation- Website- Shop- Other

What was the condition for which you sought helpWhen was the date (s) of your appointment or class.Was the treatment for you or a minor.

Did you find the premises easy to locate / or / was the home visit prompt.Was the information given prior to your visit clear and usefulWere the premises clean and presentableWere the facilities clean and adequate

What were your first impressions

Were you made to feel welcomeWas your condition discussed in fullWas the treatment suggestion clear and adequateDid you sign a full consent form

Were you made fully aware of the need to undressDid you feel that the treatment was worth the cost.

PLEASE NOW, IN YOUR OWN WORDS DESCRIBE THE EVENTS LEADING TO YOUR ATTENDANCE FOR TREATMENT AND WHAT WAS DONE TO ALLEVIATE THE CONDITION, HOW EFFECTIVE WAS THE TREATMENT AND ANYTHING THAT MAY ASSIST IN GIVING A FULL AND DETAILED ACCOUNT OF THE WORTH OF THE TREATMENT. USE AS MUCH SPACE AS YOU WISH AND SCROLL DOWN THE PAGE.

DECLARATION MUST BE SIGNED I give unreserved permission for the above testimony to be used in a public volume and for the release of comments by the therapist who treated me and discreet extracts from my Clinic case notes to be used in public with anonymity in the public document. SIGNED DATE

FAMILY MEMBER OR FRIEND NAME
ADDRESS                                                 CONTACT DETAILS

I certify that the above is a true record of the events to the best of my knowledge. I make further comment as follows. Use as much space as you wish and as many pages necessary. We are also looking at the effects of illness and the recovery on the families.      Signed                                              Date