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New Client Intake Form ~ Energy Healing & Executive Restoration

RETURN TO WHOLENESS - A high-touch, hybrid healing service and customised healing program that combines assessment, personalized protocols, and a mix of in-person and digital delivery. A full, non-performative customized healing program delivered by a student practitioner, at the doctoral-level in metaphysics, with over 25 years of experience, now being formalised.

Before moving forward, please review and sign our Client Booking Policy and Consent

Full Name

Email address

Mobile number

Address

Emergency Contact and phone number

Are you under a physician's care?

A
B

Physicians name and phone number

Have you ever had an energy healing?

A
B

When was your last session?

Do you have any particular area of concern?

Are you sensitive to touch?

A
B

Are you sensitive to fragrance?

A
B

How did you hear about us?

Please list any traumatic or life-threatening events that occurred in your life and when they happened

Do you have or have you had any allergies, medical ailments/diseases? If so, briefly explain

Release & Consent

The above information is accurate to the best of my knowledge. I understand that energy healing therapy is not intended to replace or substitute for appropriate medical care and it is advised that the client consult with his/her health care practitioner. I do forever release the practitioners from all liability of any nature whatsoever, whether past, present, or future for injury or damage which may occur as a result of my receiving energy healing therapy. I agree to hold harmless and defend the practitioner of and all actions, claims, or other legal or administrative action that has arisen or my arise from my participation in this therapy. I understand that energy practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, not interfere with the treatment of a licensed medical professional. I understand that energy healing can complement any medical or psychological care I may be receiving. I also understand the body has the ability to heal itself, and to do so, complete relaxation is beneficial. I acknowledge that long-term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself

Yes, I acknowledge and agree