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    Client Intake Form For Energy Healing

    Uploaded by

    Lasha Kvara
    This client intake form collects personal and medical information to assist a healer in providing energy healing. It requests the client's name, contact details, emergency contact, medications, medical conditions, injuries, goals for the session and areas of concern. The client acknowledges the form was completed honestly and that energy healing does not replace medical treatment. The healer agrees to perform the session with pure intention to serve the client's highest good.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Client Intake Form For Energy Healing

    Uploaded by

    Lasha Kvara
    1K views3 pages
    This client intake form collects personal and medical information to assist a healer in providing energy healing. It requests the client's name, contact details, emergency contact, medications, medical conditions, injuries, goals for the session and areas of concern. The client acknowledges the form was completed honestly and that energy healing does not replace medical treatment. The healer agrees to perform the session with pure intention to serve the client's highest good.

    Original Title

    Client Intake Form for Energy Healing

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    This client intake form collects personal and medical information to assist a healer in providing energy healing. It requests the client's name, contact details, emergency contact, medications, medical conditions, injuries, goals for the session and areas of concern. The client acknowledges the form was completed honestly and that energy healing does not replace medical treatment. The healer agrees to perform the session with pure intention to serve the client's highest good.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views3 pages

    Client Intake Form For Energy Healing

    Uploaded by

    Lasha Kvara
    This client intake form collects personal and medical information to assist a healer in providing energy healing. It requests the client's name, contact details, emergency contact, medications, medical conditions, injuries, goals for the session and areas of concern. The client acknowledges the form was completed honestly and that energy healing does not replace medical treatment. The healer agrees to perform the session with pure intention to serve the client's highest good.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Client Intake Form

    Personal Information

    Name: Birthday:

    Address:

    Suburb: State: Postcode:

    Home Phone: Mobile:

    Email: OK to email promos? Y / N

    Occupation: Status: F/T P/T Casual

    Emergency Contact Name:

    Relationship to you: Contact Phone:

    Medical Information

    Are you taking any medications? Yes No If yes, please advise:

    Are you pregnant? Yes No If yes, how far along and are there any

    concerns?

    Do you suffer from chronic pain? Yes No If yes, please advise:

    Is there anything that makes it feel better or worse?

    Have you had any injuries? Yes No If yes, please advise:

    Please indicate if any of the following which apply to you:

    Cancer Headaches/migraines Stroke

    Fibromyalgia Arthritis Heart attack

    Diabetes Kidney dysfunction Joint replacement

    Blood clots High/low blood pressure Numbness

    Sprains/strains Depression Anxiety

    Other:
    1
    Healing Information

    If at any time during the session, you feel unwell or uneasy, please advise your healer. You’re welcome to provide
    insights/experiences during the session if it will assist in the session, or you can advise upon the closure of the
    session.

    Have you ever had energy healing or Reiki performed before? Yes No

    If yes, how long ago and what was the outcome?

    Have you ever had any other holistic or natural healing performed before? Yes No

    If yes, what was it, and how long ago and what was the outcome?

    What are your goals for this healing session? Tick all that apply:

    Physical relief Yes No If yes, please explain:

    Emotional relief Yes No If yes, please explain:

    Spiritual relief Yes No If yes, please explain:

    If applicable, mark the areas of concern on the chart below:

    Client acknowledgments

    By signing the below, you agree you have completed this form as honestly and completely as possible, and will
    advise if anything changes at any time; you understand energy healing is a natural, non-invasive modality to help
    bolster your own ability to heal and should not replace urgent or essential medical treatment by a medical
    practitioner.

    Client’s signature: Date:

    Healer acknowledgements

    2
    By signing the below, you agree to perform your healing session with pure, loving intention in order to serve your
    client’s greatest and highest good, and have also advised your client of what to expect before, during and after the
    session has been completed.

    Healer’s signature: Date:

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