NAME
Mr Mrs Miss
ADDRESS
CONTACT DETAILS
Name of Client/Patient/Student
AGE…………. SEX………
Which Clinic did you attend The Chi Clinic / Home visit
Which class or course of classes.
Who was the therapist or teacher:-Tony Hardiman,
Vicky Ahern, Lee Fairweather Other…………..
How did you find the Clinic….On recommendation-
Website- Shop- Other
What was the condition for which you sought
help
When 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 useful
Were the premises clean and presentable
Were the facilities clean and adequate
What were your first impressions
Were you made to feel welcome
Was your condition discussed in full
Was the treatment suggestion clear and adequate
Did you sign a full consent form
Were you made fully aware of the need to undress
Did 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
