Energy Therapy New Client Intake Form Personal Information Name * Email Address * Date of Birth * Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone * Cell Phone Best Time to Call Ok to leave a message? * Is it all right to leave a message at all phone numbers and email? If not, please specify. Emergency Contact Name and Number * Marital Status Single Married Divorced Widowed Separated Children How did you hear about us? * Energy Therapy Modality * IET® Source Energy Support Reiki Please choose which modality you would like for this session What would you like the focus or intention of your energy therapy session to be? * Work Information Occupation * Name of Business Are you happy at your current employment? If no, please tell me briefly what you would like to be doing differently. Health Current Health Status and Health Concerns * Previous major illnesses, accidents or broken bones? * Currently under medical or mental health care? If yes, please describe. * Any prescriptions or holistic-based treatments/supplements? * When tense, where do you feel it most in your body? * Describe your sleeping patterns: Why are you seeking IET®, Source Energy Support, or Reiki energy therapy? * Have you ever had an IET®, Source Energy, or Reiki session before? If yes, how often? * What other forms of body therapy have you tried? * For Women: Are you currently pregnant? * Other If you knew you could not fail, what would you attempt to do? * Is there anything else you would like me to know about you or your circumstances before we begin? * READ our Client Communiqué and Consent Form * Please use this link to read and print our Client Communiqué and Consent Form before completing the electronic signatures below Electronic Signature * Please type your full name in the box Comprehension and Consent * Yes, I received the New Client Communiqué and Consent Form Yes, I understand the provided information and consent to this session No, I do not consent to this energy therapy session File Upload Drop a file here or click to upload Choose File Maximum file size: 27.26MB If you are human, leave this field blank. Δ
