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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.