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Help me know you better
Please take your time to fill up this questionnaire to the best of your ability. Please remember there are no right or wrong answers. In this form of healing the best practice is "First Answer that comes to your mind is the best answer". Please go with your intuition rather than over thinking the situation. Please feel free to email me if you feel stuck anywhere.
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Email *
Your FULL Name  *
If Filling for your child <18y, Please enter their full name here. 
Date of Birth (If completing for your child(ren), please enter their DOB.  *
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Age *
Current Country of Residence *
Please specify your Time Zone. AEST, IST etc.  *
Mobile/WhatsApp Number (include International codes) *
Preferred day(s) of the week and time.
Please note this is not a booking link. 
Biological Gender *
Relationship Status *
Do you have children? *
If yes, please list their ages. If no, mark as NA. *
Issues, Goals and Pain Evaluations
Do your best to answer the following questions as accurately possible , choosing the most problematic issues and rating them from 1 to 10, based on your average daily, weekly or monthly experience. A one is Mild and a ten is most severe. Using this pain scale can help us to identify the severity of the issue(s).
Describe your 1st concern 
(Please give details of any Health concerns, Physical Pains, Mental Challenges or Emotional conditions that you may be diagnosed or experiencing from)
Examples: Anxiety, Anger, Feeling Stuck, Feeling Lost, Chronic Pain, Relationship Challenges, Wealth creation, Health issues any other dis-comfort or dis-eases etc. 
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How painful, problematic or difficult is this issue (1-10)?                                           

Please rate your response from 1 being the Mild to 10 Most severe?
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Mild
Most Severe
How often do you experience it in a month?
Column 1
Once a month
Few times in a month
Many times in a month
How long has it being going on?
Column 1
Under 3 months
Under 12 months
More than a year
Describe your 2nd concern 
(Please give details of any Health concerns, Physical Pains, Mental Challenges or Emotional conditions that you may be diagnosed or experiencing from)
Examples: Anxiety, Anger, Feeling Stuck, Feeling Lost, Chronic Pain, Relationship Challenges, Wealth creation, Health issues any other dis-comfort or dis-eases etc. 
How painful, problematic or difficult is this issue (1-10)?                                           

Please rate your response from 1 being the Mild to 10 Most severe?
 *
Captionless Image
Mild
Most Severe
How often do you experience it in a month?
Column 1
Once a month
Few times in a month
Many times in a month
How long has it being going on?
Column 1
Under 3 months
Under 12 months
More than a year
Describe your 3rd concern 
(Please give details of any Health concerns, Physical Pains, Mental Challenges or Emotional conditions that you may be diagnosed or experiencing from)
Examples: Anxiety, Anger, Feeling Stuck, Feeling Lost, Chronic Pain, Relationship Challenges, Wealth creation, Health issues any other dis-comfort or dis-eases etc. 
How painful, problematic or difficult is this issue (1-10)?                                           

Please rate your response from 1 being the Mild to 10 Most severe?
 *
Captionless Image
Mild
Most Severe
How often do you experience it in a month?
Column 1
Once a month
Few times in a month
Many times in a month
How long has it being going on?
Column 1
Under 3 months
Under 12 months
More than a year
History Evaluation
This section is designed to gather information about experiences with these issues in the past, which can bring to light important issues to focus on for an ultimate healing process.
Please describe your family situation while growing up as it relates to these issues:
For example: Any relationship issues between the parents, any financial hardships, overall environment in the house when growing up. 
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What(if anything) triggered the onset of this problem? *
Are there any traumas you feel may be related to any of these issues, even indirectly? *
Please list any family members or partners who have or have had similar issues: *
Please describe anything else that may be pertinent or useful to know (from birth to now): *
Are you currently receiving any professional support with your issues? Eg. Counselling *
Are you on any prescription or Over the counter medications? *
Do you take any Ayurvedic, homeopathy or herbal supplements? *
Do you do any breathing excercises, guided meditation or any other practices that are spiritually nourishing? *
Have you had any previous experiences with any form of Energy Healing? If yes please specify the modality name and year when it was done and how long did you do it. *
Goals and Visualizations
This section is to help you create the vibration of the reality you want, which enables your subconscious computer to look for conflicts. This makes doing work with The Emotion Code easier and more targeted, which can help you to achieve your goals faster!
If you suddenly felt the perfect amount of energy and had no mental, physical or emotional pain of any kind, what would you be able to do?
If you felt really good all the time, how would you help the world?
What would your average day look like if you never had to worry about these issues again?
If these issues went away tomorrow, how would you feel?(focus on each issue at a time if you think it may be helpful)
Load up on these positive feelings. See and Feel this future in your mind! What do you feel now?
How did you find out about us? *

I understand that Harsiddhi Pancholi is not a licensed physician or counsellor. I acknowledge that she is a Certified Practitioner, and the treatments she offers are alternative or complementary in nature.

The services provided may include one or a combination of the following: The Emotion Code®️, The Body Code™️, The Belief Code™️, Space Cleansing and Quantum Healing. I am open to learning about and becoming comfortable with the holistic theories behind these healing modalities.

I understand that Harsiddhi uses The Emotion Code®️, The Body Code™️, The Belief Code™️, Quantum Healing, or any other type of energy work to release emotional baggage, rebalance the underlying energetic misalignments and imbalances and clear old belief patterns that no longer serve me that may be contributing to my physical, mental or emotional challenges.  She may use them in person or by proxy, and this is not a substitute for medical care, advice, or treatment. These practices are not intended to provide psychological counseling. The information provided, whether online or in person, is not intended to create a physician-patient relationship and should not be considered a replacement for consultation with a healthcare professional.

Harsiddhi Pancholi does NOT DIAGNOSE or RECOMMEND specific treatments. All suggestions made for any supplements or alternative therapies are based on information received intuitively and/or through muscle testing. She makes no claims regarding healing or recovery from any illness. If you have any questions or concerns about your health, you should contact your healthcare provider. Energy Work is widely recognized as a valuable and effective complement to conventional medical care.

By choosing therapies such as The Emotion Code®️, The Body Code™️, The Belief Code™️, and Quantum Healing, you empower yourself, reduce stress, and support your body's own self-healing mechanisms by restoring harmony and balance within.

Healing sessions are strictly confidential, and your personal information will never be shared with anyone without your explicit consent unless required by law. 

By entering today's date and clicking on the checkboxes below, you confirm that you have read and accepted the terms of this disclaimer. This disclaimer is intended to comply with legal requirements applicable in Australia and is recognized worldwide.

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