Book a Session
Book a Session

Request a Session or Make a Self-Referral

Use this form to request a session for yourself, or to refer someone else with their agreement. Sending the form is a request, not a confirmed appointment. KIA Healing will contact you to talk through your request, agree a time and confirm the next steps.

Not sure which service is right for you? Make an enquiry or call 07908 470 025.

How we use your information

  • Why we ask: we ask for health and wellbeing details so the practitioner can check the service is suitable and safe for you. We ask for an emergency contact only so we can reach someone if you become unwell during a session.
  • Who sees it: only the KIA Healing practitioners involved in your care. We do not share it with anyone else without your permission.
  • How long we keep it: only for as long as we need it to provide and record your sessions, and then it is securely deleted. See our privacy notice.
  • Confidentiality and safeguarding: what you tell us stays confidential. The only exception is if we believe you or someone else is at serious risk of harm. In that case we may need to share information with the right services, and where possible we will talk to you first.

Not for emergencies. This form is not monitored for urgent or emergency support. If you need urgent help, call 999 or NHS 111, or contact your GP. Complementary therapies do not replace medical diagnosis, advice or treatment.

Please enable JavaScript in your browser to complete this form.
Client Info
Treatment Preferences: Please check the box next to the treatment you are interested in:
Briefly describe the reasons you are seeking the selected treatment(s):
Emergency Contact:
Availability (days):
Please indicate your preferred days and times for appointments:
Is there any other information you would like to share with the practitioner? (e.g., preferences, specific concerns, etc.)
Declaration:
I hereby confirm that the information provided in this form is accurate to the best of my knowledge. I understand that the selected practitioner will use this information for the purpose of providing the requested treatment(s).