Intake Form
PERSONAL INFORMATION
Thank you for subscribing and taking advantage of my discount! I am excited to help you release trapped emotions for creating peace, balance, and healing in all areas of your life! Please complete the intake form at least 24-hours prior to your scheduled session. All information will remain confidential. At no given point is information disclosed or shared without your written consent. Please give yourself at least 15 minutes to complete the entire form. If you have not done so already, your next step is to schedule your emotion code session by emailing me at LaDeene@smallhealthysteps.com.
Full Name *
Your answer
Email Address *
Your answer
Phone *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
What is your occupation? *
Your answer
How did you hear about me? *
Please choose your appointment preference: *
FOR FAMILY SESSIONS ONLY
Who will be attending the session with you?
Your answer
HEALTH ASSESSMENT
What are your top 3 health concerns? *
Your answer
Have you previously attempted to resolve these concerns using another healing modality? If so, what was your experience like? *
Your answer
Have you seen a medical doctor for these issue? *
Do you suffer from any of these other concerns:
Please rate your weekly stress level. *
Never Stressed
Always Stressed
Do you actively participate in stress management activities (e.g. meditation, yoga, deep breathing, tai chi, exercise, etc.)? *
Your answer
How would you like to feel after 90 days? *
Your answer
Do you have any pets?
Your answer
Do you have a pet with any of these issues:
Have you seen an Emotion Code Practitioner before? *
How familiar are you with energy healing/energy medicine? *
How committed are you in addressing your top health priorities? *
Not too committed
100% committed
Thank you for taking the time to complete my intake form. Please read my cancellation policy and client agreement carefully before submitting.
CANCELLATION POLICY
*24-hour cancellation notice is required to avoid being charged for your session.

Payment can be sent via Venmo (www.venmo.com/ladeene-hagner) prior to your scheduled session. You can also pay cash in-person.

It is important that you be on time for your scheduled appointment. You are welcome to call in advance to request an earlier or later time. I will be happy to honor your request if other appointment times are available. However, simply arriving late changes the course of treatment for yourself and others. Should you be late for any reason, your session may be shortened in order to accommodate others whose appointments follow yours.
CLIENT AGREEMENT + DISCLAIMER
This policy has been established in order to provide the highest level of service to all of my clients. Please read the policies carefully.

1. I understand that The Emotion Code, as well as the Body Code System, as taught by Dr. Bradley Nelson, (hereinafter called “these methods”), and as practiced by the practitioner listed above, seek to identify and eliminate underlying imbalances by releasing energetic imbalances in the areas of energy, circuitry, pathogens, structure, toxicity, and nutrition. These methods of energy healing promote harmony and balance within, relieving stress and supporting the bodyʼs natural ability to heal. Energy healing such as these methods is widely recognized as a valuable and effective complement to conventional medical care.

2. I understand that releasing trapped emotions, or the correction of any other energetic imbalance using these methods as practiced by the practitioner listed above, is not a substitute for medical care. This information is not intended as medical advice and should not be used for medical diagnosis or treatment. Information received is not intended to create any physician-patient relationship, nor should it be considered a replacement for consultation with a healthcare provider, nor is it meant to replace any medical treatments as ordered by any physicians nor any other medical care you have been advised to seek by them. I further understand that these methods are not a replacement for any professional psycho-therapeutic or counseling sessions in the treatment of any mental health issues or disorders.

3. I understand that if my practitioner makes any suggestions regarding supplementation of any kind, such as vitamins, minerals, herbal preparations, essential oils or any compounds or any other external remedy of any kind, that I use or ingest any such at my own risk, with the recommendation that I seek the advice of a physician before using any remedy suggested by my practitioner.

4. I understand that in approximately 20% of sessions, the release of trapped emotion(s) or other energy(s) may result in “processing,” where echoes of the emotion(s) or other energy(s) released may manifest in temporary physical or emotional discomfort, and that this “processing” appears to be a normal part of regaining energetic balance.

5. I understand that my practitioner makes no claims as to healing or recovery from any illness I may have now, nor the prevention of any illness I may have in the future, and that no guarantee is made towards validity. I further understand that the use of any information I receive is at my own risk.

6. I understand that if I have health concerns, I am recommended to seek advice from an appropriate medical practitioner
before making any decisions about my health, and that this information is offered as a service and is not meant to replace any medical treatment.

7. I understand that these sessions are confidential, and that any personal information would be used anonymously for educational and research purposes only, subject to any exceptions governed by laws of the State of residence of my practitioner listed below, or of Federal laws and regulations, and that identifying personal information such as my last name and city will be deleted to maintain my privacy, unless required by law.

8. I understand that I am advised to be self-informed about this work by visiting Dr. Bradley Nelson's website: www.healerslibrary.com and/or by reading his book The Emotion Code.

9. I understand that by submitting this form, I have agreed with the policies listed above and fully consent to participating in an Emotion Code Session with Practitioner LaDeene Madrigal.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy