Energy Healing Intake Form Please complete the form below if this is your first Energy Healing experience with us. Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Occupation How did you find me? * Emergency Contact (Name, Relationship, Phone) Are you currently taking any medications? * Yes No If yes, please list name and use: Do you suffer from chronic pain? Yes No If yes, please explain: Have you had any recent injuries or surgeries? If so, please explain what type of injury/surgical procedure and its cause/reason. Do you have any allergies or sensitivities? Yes No If yes, please explain: Please indicate any of the following that apply to you: chronic low back pain stress anxiety feeling worried or on high alert panic attacks fatigue or sluggishness low self esteem or insecurity autoimmune issues hip injuries or tightness hormonal imbalance depression reproductive issues lack of creativity or motivation low libido fear of intimacy digestion Issues, abdominal pain, bloating, or constipation feelings of guilt or shame trouble letting go of past mistakes kidney disfunction feeling stuck or lacking ambition hernia / rupture tightness in chest, shoulders, arms, and hands high/low blood pressure heart attack insomnia feelings of anger, paranoia, and trust issues sense of loss or grief blood clots gets sick easily fibromyalgia diabetes stroke neck tension chronic sore throat grinding teeth / TMJ difficulty with confrontation feeling a lump in the throat headaches/migraines sinus pain or pressure pessimistic look on life trouble trusting oneself poor circulation chronic exhaustion lack of direction or drive lack of faith joint pain, stiffness, or arthritis skin condition feeling disconnected other (explain below): How would you describe your lifestyle? Consider: Dietary Habits, Exercise Habits, Rest, Stress Levels, Emotional well being, Work-Life Balance, Overall Happiness + Satisfaction. Have you ever received energy healing therapy before? Yes No What has your experience been in any previous energy healing sessions? What are your goals for seeking energy work? * Do you now, or have you recently had any respiratory or flu symptoms? * Yes No Have you had a fever in the last 24 hours? * Yes No Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms? * Yes No Would you prefer your practitioner to wear a mask during your appointment? I have no preference, without is just fine. Yes, please! I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. * Please Initial. I understand that, because energy healing involves touch and close proximity over an extended period of time, there may be elevated risk of disease transmission, including COVID-19. * Please Initial. I understand that energy healing therapies are not a replacement for medical treatment, and that the therapist may only perform treatments within his or her scope of practice and level of comfort. Anything said during this session shall not be regarded as medical advice, treatment, diagnosis, or prescription. I understand that the therapist may refuse service at any time for any reason, and that clients may be referred to a medical professional if the therapist feels this is necessary. I understand that it is my responsibility to inform the therapist of any changes to my medical health profile and that the therapist will not be held liable for anything resulting from my failure to do so. I agree that I have been given sufficient opportunity to ask questions and make specific requests in order to make my treatment time as comfortable as possible. Please Initial. * Please Initial. Thank you!
