Child Consultation Form



Some Helpful Guidance for Parents/Guardians for Reflexology and Child Appointments:

All children under 16 must be accompanied by a parent or guardian and must stay with them throughout the session unless the therapist and child agree together that a treatment can be given alone.

If you do not want to answer any question on this form then please leave the field empty.

A full treatment plan can be pre-prepared saving unnecessary waiting time for your child if this form is filled in and submitted to Dr Jones before the appointment.

If you think that working on your hands or feet first to demonstrate to your child what is going to happen will help him/her to relax and go ahead with the treatment then please advise us beforehand.

Your child lies on a padded comfortable table during the treatment with hot water bottles/blankets as appropriate (weather dependent!)

For much younger children - if you think your child will relax better initially by bringing some kind of comforter e.g. a toy or a blanket that they sleep with that may help them relax, please use your own discretion and feel free to bring this along.

Please ensure you have read the disclaimer section at the end of this form, as I will ask you to sign it at the beginning of the appointment.

If you have any further questions I will be pleased to help. If you have a problem completing the form online this can be emailed to you.

Kind Regards
Melanie

Dr Melanie Jones (PhD)





















First Reflexology Treatment







By submitting this form you agree to tell the therapist if there are any changes to any of the information in this or the supplemental forms.

Disclaimer: I accept that the information provided is a true and accurate reflection of my state of health. I give permission for treatment to be carried out. I have had each treatment explained to me and accept full responsibility. I will not change any medication I am taking without first consulting my medical practitioner and if I am taking anti-depressants I have my doctor's approval for treatment. I realise that my Dr Melanie Jones PhD is not a medical doctor, and cannot prescribe, diagnose or treat for a specific condition. . Reflexology for example can relieve tension which in turn helps to improve nerve and blood supply and to bring the body into balance. For Ear Reflexology I agree to remove the tourmaline balls 48 hours after treatment, leave them off for 48 hours and then re-apply more tourmaline balls. This application cycle can be continued until the issue has stabilised.