Client intake form & consultation booking

Book Your Session

Please complete the form below prior to booking your first appointment

This form assists Dr Safeera K in understanding your health background and preparing for your session.

Please complete it as fully as you are able. In craniosacral therapy and neuro-somatic medicine, the body functions as an integrated whole — all information is potentially relevant, regardless of whether it appears directly related to your presenting concern. All information is held in strict clinical confidence.

After completing the form you will be directed to our online booking system where you can select the preferred date and time for your initial Arc consultation with Dr Safeera K MD.

Step 1 of 5

01 · PERSONAL DETAILS

Full Name

First

Last

Preferred name

Date of birth

Age

Gender

Contact number

Occupation

Emergency contact name & number

Referring practitioner (if applicable)

Current pregnancy? (Yes / No / N/A)

INFORMED CONSENT

The sessions offered at The Reset Room are delivered by Dr Safeera K — a registered medical doctor with additional training in craniosacral therapy, clinical hypnotherapy and neuro-somatic medicine. Sessions draw on her clinical background and are integrated within a medically informed framework. They are designed to complement — not replace — any specialist, emergency or ongoing medical care the client is receiving elsewhere.

Sessions may include craniosacral therapy, nervous system regulation, somatic awareness, subconscious pattern exploration and body-based therapeutic approaches, depending on the client's presenting needs and treatment plan.

I have read, understood and agree to the informed consent information provided above.

By siging below I confirm that I understand and agree to the following:

No specific outcome or result can be guaranteed.
Sessions may involve gentle physical touch, guided inquiry, emotional processing and increased awareness of physical or emotional patterns.
Temporary physical or emotional responses may arise as part of nervous system processing and integration.
I remain responsible for my own healthcare decisions and for maintaining appropriate specialist or emergency care where required.
I have disclosed all relevant medical conditions, medications, injuries, surgeries, pregnancies and diagnoses to the best of my knowledge.
I may pause or stop a session at any time and will communicate any discomfort.
All personal information is held confidentially within professional and legal obligations. Exceptions apply where there is risk of harm or a legal requirement for disclosure.
A minimum of 24 hours notice is required for cancellations. Late cancellations may be charged at the practitioner's discretion.
These sessions are not appropriate for medical emergencies or acute psychiatric crises. In such circumstances, appropriate emergency or specialist care should be sought.

For paediatric clients: I confirm I am the parent or legal guardian of the child and consent to treatment on their behalf.

Client / Guardian full name

First

Last

Date

pain indicate (Yes

Client / Guardian Signature

Clear Signature

Dr · Safeera K · MD · The Reset Room · Houghton · Johannesburg drsafeerakholvadiamd.co.za

All clinical information is held in strict confidence in accordance with applicable medical ethics and data protection obligations.