Client Details Form Please complete this form prior to your first consultation or before starting the Mindful Eating Program. If you are unsure of one of the questions please feel free to reach out to us on 0406 168 599 or email email@example.com. Thank you! Title:First Name:Last Name:Date of Birth:Postal Address:Preferred Phone Number:Email address:Sex:FemaleMaleOtherOther:Carer / Guardian / Emergency Contact and Phone number:Country of Birth:Aboriginal or Torres Strait Islander:NoYesLanguage/s spoken at home (if not English):Name of GP and/or medical practice:How did you hear about Stay Nourished?Would you like to stay up to date with Stay Nourished? I would like to receive information from Stay Nourished about upcoming workshops, educational events or posts.* Note that we respect your email privacy, we promise to protect your details and will not send you any junk mail.Consent* I give consent for my information to be collected to:• Enable me to receive medical nutrition therapy and/or participate in group sessions such as the Am I Hungry? Mindful Eating Program • Provide me with education and support in individual consultations and/or in weekly workshops • If I am attending the Mindful Eating Program I give permission for my information to be used in non-identifiable statistics (for program evaluation) • I understand that I may review information held about me and to withdraw my consent for the collection of further information by making a formal request to Stay Nourished. This iframe contains the logic required to handle Ajax powered Gravity Forms.