Your First Name (required)
Your Surname (required)
Profession
Date Of Birth
Marital Status (required) SingleMarriedDivorcedWidow
Gender (required) MaleFemale
In a Relationship? (required) YesNo
No. of Children (required) None12345678+
How did you get to know me? (required) GoogleFriend RecommendedFacebookMeet UpTwitterYouTubePoster/FlyerTalk given by MalTao GardenTantra FestivalOther
Other
Address
Mobile (required)
Email Address (required)
Preferred Method of contact PostMobileEmailNot to Contact
Doctor's Name And Address
Are you free from any sexual transmitted diseases? (required) YesNo
Allergies YesNo
Epilepsy YesNo
Heart Problems YesNo
Headaches YesNo
Heyfever YesNo
Blood Pressure Problems YesNo
Depression YesNo
Back Problems YesNo
Have you had any serious illnesses/operations/psychiatric Treatment/counselling or any other therapies over the last five years? YesNo
Have you taken any antidepressants? YesNo
Help with sexuality YesNo
Help with intimacy YesNo
Help with love YesNo
Find life long partner YesNo
Improve existing relationship YesNo
Any other?
What are your fears during the session?
What are your boundaries during the session?
*Hold CTRL/ALT to select multiple options Death of a loved oneDivorce of separationLoss of a RelationshipPhysical IllnessDisablityLoss of employmentStress at workPovertyRetiermentPoor housingGetting oldGrowing upAddicationsTaking care of the elderly, sick or childrenExamsRelatives moving awayPromotionHaving a babyGetting MarriedChildren leaving homeLearning difficultiesLeaving homeGoing on holidayHeavy Physical WorkLong HoursPoor working environmentWorking to deadlinesConstant TravelToo much responsibilityThe crying babyBeing unhappy about your appearanceBeing concerned about your sexual identityFear if being raped of attacked
other
*Hold CTRL/ALT to select multiple options Feeling Constantly ExhaustedNo Interest In LifePanicIrritabilityLack Of ConcentrationCrying EasilyAttention SeekingHypreactivityRapid SpeechRapid ThoughtsThink About Food A LotParanoiaPhobiasFeeling Of Gloom And DoomFeeling Life Is Not Worth LivingRestlessnessCompulsionObsessionLoss Of Interest In SexTight Chest Or ThroatShakingDizzinessDiarrhoeaWindInsomniaBreathing DifficultiesThumping HeartExcessive SweatingSwallowing ProblemsLoss Of Appetite And WeightHeadachesDifficult To Experience Regular OrgasmTinnttus (Ringing In The Ears)Aching All Over other
Have you had a massage before? YesNo
By ManWomenBoth
What Massage movements do you like? *Hold CTRL/ALT to select multiple options Deep PressureMixed MovementsGentleFeathering
Would you like a female chaperone to be present during the treatment? *Female chaperon is only available during weekends and weekdays after 6pm with 48 hrs notice and an extra payment of £50 YesNo
*Hold CTRL/ALT to select multiple options HeadNeckShouldersUpper BackThighsLower backBreastArmsLower AbdomenGroin AreaButtocksAnusFeetGenitalia (Yoni)MouthFace
Any other areas?
*Hold CTRL/CMD to select multiple options HeadNeckShouldersUpper BackThighsLower backBreastArmsLower AbdomenGroin AreaButtocksAnusFeetGenitalia (Yoni)MouthFace
I have been shown a THE TREATMENT CARD setting out all that the treatment sessions entail including exploring Sexuality, Love and Intimacy through Tantric rituals and bodywork YesNo
I have read and understood the Treatment Card, read the contents in the Tantric Journey Brochure and / or Tantric Journey website (tantricjourney.com) YesNo
I have watched the u tube at the bottom of the treatment card “What is the difference between the Tantric Healer and the Lover ?” (https://youtu.be/CRehoXWNG0w) YesNo
I have read Mal Weeraratne's book, 'Emotional Detox, A Woman's Guide to Healing and Awakening' YesNo
I understand that the said treatment is client lead, and if at any time I request the treatment to stop, the therapist will cease the treatment immediately YesNo
I understand that Mal Weeraratne (Therapist) will verbally fully explain the treatment during the consultation process, prior to the session YesNo
I therefore give my full consent to a series of such treatments upon any part of my body, with the use of any part of the therapist’s body. (There will be no penile – vaginal penetration during the session YesNo
I am aware of the Healing Crisis and How I may feel after a session. I have read the Tantric Journey Support available after a Session YesNo
I am proceeding with the session fully aware of what the treatment involves
Whilst many clients have had positive outcomes from Emotional Detox sessions, this modality has not been subject to scientific evaluation, therefore no scientific claim is made that Tantric Journey results in emotional healing. Significant positive change is often seen but cannot be guaranteed
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