Lift Your Life Application

You are invited to complete this short application form. The information will help us to allocate our resources with the most efficacy. Your responses are held in strict confidence.

Personal Contact Details

First Name

Last Name

Address

Address 2

City

Postcode (scroll to end for Australian states)

Country

Mobile Number

Date of birth

Occupation

Applicant Consent

Please read our Consent For Treatment (view PDF) and acknowledge that you have understood and agree.

Charitable Service Means Assessment

As a charitable service our duty is to prioritise assistance to those of limited financial means. For this reason we respectfully ask:

If you have a government Healthcare Card, please enter the number here.

Other reason for requesting financial assistance. Please specify:

If you do not meet our means requirement, we can offer discounted healing in packages of five sessions at a cost of $355.

Health Information

Please provide details of your treating GP/medical practice.

Please tell us about any medical issues, past and current.

Are there any major stressors in your life at the present time or recently?

Are you being treated for any mental health issues? If you are, please list.

Condition for which you seek assistance. Please be as detailed as possible.

How long have you been experiencing this condition?

Do you have a spiritual belief system?

Is there anything else you'd like to tell us?

How Did You Hear About Us?

If you selected other, please tell us more.

Applicant Feedback and Agreement

Once you are accepted onto the program, you are encouraged to honour your commitment for your journey to health. We will honour our part by allocating a practitioner for your sessions and we ask that you honour your part by participating in your scheduled sessions.

At the conclusion of your sessions you will be required to complete and return to The Well Being Initiative a feedback form and two Burns Inventory Checklists. Whether feedback is positive or negative, it is important for statistical analysis and to demonstrate the efficacy of our programs. It also helps us understand how we can improve our service.

I agree to provide feedback on my experience at the end of the sponsored sessions e.g. improvement in my condition, how I was helped, changes I've noticed. The Well Being Initiative may collect and store such feedback in written or media form and are
authorised to utilise all or part of the feedback for program development, sponsorship, promotion and marketing purposes. You may opt for confidentiality and keep your identity private.

To sign, type: SIGNED BY [INSERT YOUR NAME]

Submit

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