Please enable JavaScript in your browser to complete this form. All About You Wellness Centre Date *Name *FirstLastOccupation *Date of Birth *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHK ID Card/Passport Number *Contact Number *Email *Gender *MaleFemaleNon-BinaryPrefer not to sayHave you ever spoken in public before? *YesNoIf YES, how would you describe your experience?What parts of public speaking do you feel you would like support with? *Delivery and StyleFear and MindsetAn upcoming SpeechStructure & ContentPowerPointOthers (Please state)Describe in your own words what you would like to accomplish out of your Public Speaking Coaching session(s). *Terms and Conditions Cancellations must be made at least 24 hours prior to the scheduled appointment. If cancellations are made less than 24 hours the full session fee will be charged. Should the client fail to show up, the full session fee will be charged. All prior payments are non-refundable and non-transferable, except in special circumstances and All About You (‘AAY’) reserves the right to the final decision. The Client agrees that all practices done on, for, or even by them at AAY are done with their full consent and at their will. The Client attests that they have no mental or psychological ailment/disorder and are not on any psychiatric or psychological treatments and/or drugs. The Client agrees to indemnify, release, remise and forever discharge, the treating practitioner, AAY, its employees, its consultants, its property owners or anyone one at AAY from any obligation or liability whatsoever, all claims, demands, damages, injuries, actions or causes of actions whatsoever, before, during or after volunteering to participate in such sessions. The Client is aware of the modalities of therapy used and understands that the result may also depend on external factors and the clients’ own efforts. The client is aware that the session is private and only involves the client and therapist, and thus the client shall not bring children, friends or relatives to the session room unless they are related to the case and previously discussed with the therapist. The client understands that pets are not allowed at All About You centre and shall not bring any pets/ animals to the centre under any circumstances. Privacy By signing this form, you understand and agree: Your personal data (name, contact details, interests,) may be used by AAY to contact you and inform you about our latest news, events, promotions, offers, workshops, seminars and other exciting happenings at AAY. Please note that you may change your mind at any time and ‘opt-out’ of our mailing list by either writing to us at info@soniasamtani.com or by clicking ‘Unsubscribe’ in any of our email communications. Confidentiality All information discussed in the sessions will be treated as confidential information and will not be disclosed to any third party unless prior permission is granted or unless disclosure is required by law; However, counselors are ethically and/or legally required to disclose confidential information to the appropriate authorities in four kinds of circumstances: If a client indicates that they or another person may be a danger to themselves or others In the case of apparent, suspected or potential child abuse or neglect If clients report sexual abuse by a regulated health professional When a court issues a summons for records of testimonyI have read and accepted the above terms and conditions above.Please type your name to confirm all the information above. This will serve as your e-Signature.Date Signed:Submit