Client Intake Form

Client Intake Form for Remote Healing Session

Kindly complete this form prior to your session.

Please also look for additional instructions for your session.

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Are you coachable?

Yes

Please prioritize the areas you think we need to focus on for your session(s):

Please list any other diagnosis or diseases not listed from above:

Do you have a history of psychological disorders? If so, please list:

Do you take recreational drugs? If so, what kinds and how often?

Do you drink? If so, how often?

Please list any past or upcoming surgeries that you have had (and approximate dates):

Please list any medications, vitamins or herbs that you are taking:

The above information is accurate to the best of my ability. I understand that energy healers do not diagnose disease or prescribe drugs, and that energy healing sessions are not a substitute for medical care. I agree to alert my practitioner of any physical/emotional changes as they occur. I also understand that a missed appointment may incur charges that I must pay.

I have read and agree.

Your session will remain private and confidential, unless you have given permission to share it. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Empowering Wellness, LLC and all its employees from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with our session(s).

I have read and agree.

Is there anything else you want me to know about you?

Will you please bring to your session(s) the following:

Water

Pen and paper

Your goals

By typing my name below, I comply that I have read and agree with all of the disclosures, and filled out the form to the best of my ability.