Intake Form
Name: *
Birth Date: *
Address: *
Best phone number to reach you: *
Email: *
Best way to reach you: *
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Emergency contact & phone number: *
Briefly describe the problem(s) you wish to address in our sessions. *
Describe any previous experience you have had with Integrative Health Practitioners. If you have never seen a Holistic Practitioner, please type none. *
Check all that apply. I have or am... *
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Please describe anything in your current and/or past history (accidents, injuries, surgeries, hospitalizations) that you think I should know about. *
I understand that the energy medicine sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner. I further understand that energy medicine should not be construed as a substitute for needed medical attention. Energy medicine practitioners do not diagnose, treat, or prescribe for medical conditions. Energy medicine brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting more subtle energies. I have also read the information in the Energy Medicine Services and Disclosure Statement, understand it fully, have discussed any questions or matters of concern, and agree to abide by its terms during our professional relationship. By typing your name, you are certifying that you agree with this statement. *
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