Client / Student Information
Please complete this form in as much detail as possible.
A fundamental element energy healing is allowing and flow. I invite you to be open to receiving the energy and wisdom of the practice and modality.
The essence of Qigong is presence and awareness... I invite you to approach your self-care and healing with this in mind each time you come to practice or receive healing. Sometimes energy that is stagnant or trapped in the body can be released through practice and receiving healing, this can manifest as an emotional release or even feelings of nausea.
Always practice at a level that resonates with the wisdom of your body, doing less... being more.
Date of Birth
Occupation / Main daily activities
Emergency Contact Name
Emergency Contact Phone
Wellbeing information - please select all that apply:
I have a healthy mindset
Minor problems throw me for a loop
I find it difficult to get along with people
I am unable to stop thinking about my problems
I feel frustrated, impatient, or angry much of the time
I experience feelings of tension and anxiety
I feel calm and peaceful
I have a lot of energy
I am a happy person
I take the time to relax and have fun daily
I often feel downhearted or blue
I often feel worthless, inadequate, or unimportant
I smoke cigarettes or consume other addictive substances
I drink more that 3 standard alcoholic beverages per week
I consume foods high in sugar or 'fast / take-away foods' on most days
I have a regular meditation or other 'self-care' practice
I take time to have fun and experience leisure
I often feel stressed and tense
I get good quality sleep, 7-9 hours per night
Do you have any other chronic or recurring illnesses, diseases or problems?
Do you currently have any physical injuries? If yes provide details
Do you have low blood pressure?
Are you pregnant?
Please select any of these that relate to you
Back and/or neck pain
Have you previously practiced Qigong?
Have you previously received energy healing (Pellowah, Reiki or other)
Please tell me about anything else you feel is relevant, such as major trauma, personal loss or misfortune that you may have experienced or be experiencing.
Terms of Service
All information collected in this form and discussed in your Qigong and/or Personal Qi Healing session will remain confidential at all times.
Please understand that recovering from a chronic, complex illness requires a commitment of time, energy, and resources. Progress can often be cyclical rather than linear.
I stay in contact with my students and clients via email. You will receive emails in relation to upcoming offerings and services and you can unsubscribe from these emails at any time. I will not share your personal information with anyone.
Personal Qi Healing
I require 24 hours notice should you elect to cancel or reschedule an appointment. If you fail to attend a scheduled appointment without notice then the full cost of the session will be charged.
Qigong classes, workshops, trainings & events
With regard to Seasonal series classes, if you miss a class you may make up that class at any other Seasonal series class during the period of the series. If you do not make up any missed classes during the period of the series you will forfeit the missed classes.
There is a strict no refund policy in relation to workshops, trainings and events. In the event that you are a no-show for a workshop or other event your pass will be forfeit.
As an Energy Medicine Practitioner I do not diagnose, prescribe or treat disease, or act as a medical practitioner. Energy medicine is a complementary healing modality and it does not replace the treatment received from allopathic or traditional health care providers.
Agreement to Terms of Service
By filling out the required information, you agree that you have read and accept the above terms of service. You agree that you assume any and all risk and take full responsibility and accountability for yourself.
I agree to the above Terms of Service
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Terms of Service