Lift Your Life Application

Lift Your Life Initiative

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 $295.

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

We will ask you for feedback at the conclusion of your sessions. Whether feedback is positive or negative, it is important that we know how we can improve.

I agree to provide feedback on my experience at the end of the 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 will have the option to remain anonymous.

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

Submit

Received 5 Free Sessions And Feel You Need More Support?

Another five sessions can be approved up to a maximum of 10 sessions. The circumstances under which a further five free sessions may be approved are if the Practitioner feels the sessions are warranted; the Client has provided written feedback through a statement of Benefit form; and funds are available to pay the therapist. If we are unable to offer you an additional 5 free sessions, you may choose to purchase more sessions at a highly discounted rate of $295, payable in advance.

Contacting the Administrator

Should you wish to contact the program Administrator to offer feedback prior to the conclusion of your sessions, you can do so by emailing: liftadmin@thewbi.org.

If you are dissatisfied with any part of the progress or management of the healing sessions, we will try to help resolve the issue.

If you feel your practitioner and the therapy has been of value to you please let us know.

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Contact

Head office:
213 Martinsville Road
COORANBONG NSW
AUSTRALIA 2265