Download Therapeutic Intervention – Confidential Data

Therapeutic Intervention – Confidential Data
Name of Patient
Patient’s Location
(City / State)
Name of Referrer
(if different from the Patient)
Contact phone no
Email address
Skype name
Date of birth of the patient
Gender of patient
Ethnic group
Spiritual / religious persuasion.
Next of kin / significant other
NOK contact email / phone
Referral From
1. Self-referral
2. Family member
3. Friend
4. Medical practitioner
5. Other therapist
6. Referral from a religious group or
church minister
7. Referral from social services or other
public service organisation. Please state
which
Medical diagnosis (if any)
Name of Referrer
Therapeutic Intervention – Terms and
Conditions & Informed Consent
Aims and Objectives.
The primary aim of this procedure is to give aid and assist you in relieving the distress that you or a
person close to you is experiencing. In addition, the primary objective is to provide evidence that
these procedures work. Your request for assistance is helping to provide such evidence.
Methods employed
For remote methods two practitioners are employed and the procedure is conducted from a
distance by telepathic and clairvoyant methods. The Patient will not be aware when the procedure is
performed and you will be informed with a report when the procedure has been completed. The
remote method is ideal for patients who are below the age of consent and for those who are too
incapacitated to give consent or are detained within mental health institutions.
Intervention Recordings
It is standard practice to record all consultations for reasons of Patient protection and for detailed
examination of dialogues during the consultation and therapeutic intervention. Recordings are
therefore more detailed and comprehensive than a written summary.
A small deposit
Upon receipt of this form with your authorisation, together with a deposit of £10 your case will be
attended to and you will be sent a recording of the intervention together with instructions for
keeping safe and heathy.
Feedback Reporting
After a few days you will be asked for feedback on the success, or not, of the intervention.
In the event of a positive outcome of the intervention you may agree to provide a written
testimonial to support the use of the intervention method. It is therefore important for you to be
registered on our website, so that you can submit your own testimonial if you so wish.
Your testimonial could be used to provide evidence that the method works. Your testimonial will
need to be truthful and written anonymously or with a pseudonym for confidentiality.
Confidentiality & Anonymity
The information collected about your treatment, experience and your views is to be used for your
benefit and for bona fide research and teaching purposes only. You and all members of your family
are assured of absolute anonymity and confidentiality in the use of the information collected. Under
no circumstances whatsoever is your name or any other personal information to be used for any
purpose whatsoever.
Protection & welfare
Your welfare is of the utmost importance and you may be assured that all means will be taken for
your protection during the procedure.
Financial Considerations
The client (signed below) agrees to pay the balance of £90 for consultations and interventions
according to the schedule of charges on the Fees and Bookings page of the Practitioner’s web site at
http://www.tjpalmer.org/fees-and-bookings/
Your signature below is confirmation that you have read and understood these Terms and Conditions
and you give your Informed Consent, either on behalf of yourself or a client of your own, or for a
friend or family member.
Informed Consent
Please write clearly the Name of Patient who shall be the subject of the procedure. If you are giving
consent for the procedure on behalf of a client of your own or a friend or family member please state
clearly your own name and your relationship to the Patient.
Name of Patient ______________________________________ Age ____
Signature
Gender M / F
Date
Signature on behalf of
Patient named above
Relationship to the Patient
Please complete this form and return by email to [email protected]
Important: If you have not yet registered on the web site please do so now so that we can proceed
with your remote procedure.