Energy Healing Session Intake Form

Please fill out and submit this form at least 48 hours prior to your initial appointment. Required fields are marked with a red asterisk. The information you provide is held as private and will not be shared without your expressed permission.

General Information
Name*
First Last
Primary Phone*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Appointment Scheduling*
- Select All
- M-Fri: 10 am to noon ET
- M-Fri: 2 to 4:00 pm ET
- M-Fri: 6 to 8:00 pm ET
Please check all times you are available Eastern Time.
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Presenting Issue(s)
Date of Onset*
MM slash DD slash YYYY
Initiating Cause*
Contributating Factors*
Previous and Current Treatment for Above*
Current Medications/Supplements.*
Lifestyle
Occupation & Lifestyle*
Employment, child rearing, caregiver
Physical Exercise*
Please list activities and amount of time you engage in them per week.
Allergies and Sensitivities*
Food and environmental. Are you on a special diet?
Please describe any regular use of alcohol, recreational drugs or tobacco*
Daily, weekly, occasionally
Medical History
Please list any significant injuries or accidents you've had.*
Any mental or emotional issues presently or in the past? Depression, anxiety, eating disorders or substance abuse?*
If so, include any diagnosis and current medications.
Do you have any cardiovascular/heart related health issues?*
High/low blood pressure, disorders, attacks, past surgeries, pacemaker, etc.
Please list any other medical history I should be aware of.
Year of Birth*
Healing Session Preparation
What are your passions and vision for your life?*
What would you like to change as a result of your healing session?*

General Information

Presenting Issue(s)

Lifestyle

Medical History

Healing Session Preparation

Footer