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
Emerency Contact Name*
First Last
Emergeny Contact Phone Number*
How did you hear about my healing practice?*
Would you like to be added to my email mailing list?*
- Yes
- No
Presenting Issue(s)
Date of Onset*
MM slash DD slash YYYY
Initiating Cause*
Contributating Factors*
Previous and Current Treatment for Above*
Current Medications/Supplements.*
Please specify what each medication is for and duration of treatment.
Lifestyle
Occupation and Lifestyle*
Employment, child rearing, caregiver
Physical Exercise*
Please list activities and amount of time you engage in them per week.
Dietary Habits*

Are you on a special diet?
Allergies and Sensitivities*
Food and environmental
Please describe any regular use of alcohol, recreational drugs or tobacco*
Daily, weekly, occasionally
Medical History
Please list any injuries or accidents you have had, and have presently.*
Please list any traumatic or threatening events in your life and the year of occurrence.
Divorce, deaths, depression, abuse, accidents and other significant events.
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 surgeries you have had and when.*
Please list any pertinent medical history I should be aware of and dates.*
Auto-immune, endocrine, musculoskeletal, neurological, digestive, respiratory, reproductive, urinary, ear/nose/throat, infectious diseases, vascular, etc.
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?*
Anything else that you would like to add:*

General Information

Presenting Issue(s)

Lifestyle

Medical History

Healing Session Preparation

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