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Name of client *

First Name

Last Name

Birthday *

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Name of parent/guardian (if under 18)

First Name

Last Name

Address *

Please provide your address to calculate distance. All sessions 4km+ from H4A3B8 will be charged $15 in additional travel fees.

Address 1

Address 2

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Phone *

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Gender *

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What do you hope to accomplish with our energy healing session? Check all that apply. *

Relaxation

Stress reduction

Pain reduction

More energy

Speed healing

Emotional trauma release

Shifting habits

Detoxification

Mental freedom

Spiritual alignment

Remove energy blocks

Other (Please explain below)

How did you hear about us? *

Internet search

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Referral

Are you sensitive to touch? *

Yes

No

Are you sensitive to fragrance? *

Yes

No

Have you ever had an energy healing session before? *

Yes

No

Are you currently receiving medical treatment for other conditions?

Yes

No

Do you take any vitamins, minerals, herbs, and/or homeopathic medicine? *

Yes

No

Are you currently taking prescription medication? *

Yes

No

Do you have any health conditions that you would like to share? *

Yes

No

Have you had any surgeries in the last 5 years? *

Yes

No

Please type your name if you agree. *

First Name

Last Name

Please enter today's date: *

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