CURRENT MWH Intake Form

Claire M. Schwartz
BA, Reiki Master Teacher, Spiritual Counselor, Interfaith Minister Certified Professional Coach,
Grief Healing Expert

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Date:

Date

Name:

Date of Birth:

Date

Age

Street Address:

City, State and Zip code:

Phone:

Email Address:

example@example.com

Emergency Contact - Name/Number:

Relationship

Phone #

I, the undersigned, understand and acknowledge the following:

I give p ermission to have the Reiki System of Natural Healing administered by touch , and understand that any of the following techniques may be used: hands on, off, above or away from the body; Brushing; Smoothing; Tapping; transmission of Reiki energy through eye s or breath; using the whole hand, or fingers (individually or gathered together)
The Reiki System of Natural Healing session is classified as spiritual healing , and is intended for stress reduction and relaxation .
If I am uncomfortable in any way during my session I have the right to question my practitioner and/or request that the session be terminated. If I experience any pain or discomfort during the session, I will immediately inform my practitioner so that the touch may be adjusted to my l evel of comfort. I understand that comfortable clothing is required at all times during my Reiki session.
Any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
The Reiki System of Natural Healing does NOT take the place of medical or psychological treatments or advice. Reiki Practitioners do not diagnose conditions, prescribe or perform medical treatment, or interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment I have. I affirm that I have stated all known medical conditions in t he following questionnaire and answered all questions honestly. There are no claims or guarantees of diagnosing, healing or curing disease.
I have agreed to receive S piritual C ounseling & Coaching from Claire M. Schwartz at Miriam’s Well Healing LLC by my personal choice . I understand that this is not psycho therapy , psychiatry, social work or medical practice. If I should experience any medical or psychological symptoms which might require the attention of a licensed health practitioner, I will see k such assistance separate and apart my coaching sessions. I understand if Claire M. Schwartz observes any signs of disorders or conditions requiring the attention of a licensed professional, she may recommend I see such a professional, and would not be a ble to continue with me in the capacity of a coach if I should refuse.
In the absence of a court order, written permission from me to do otherwise, or impending potential harm to myself or others, I understand that my confidentiality will be fully honored. However, I understand a coaching relationship is not afforded the same status as a doctor - patient relationship by the courts, and a court may, in some circumstances, be able to compel testimony.
I will not hold Claire Schwartz or Miriam’s Well Healing LLC liable or responsible in any form or fashion for actions taken or not taken by myself or anyone else.
Canceled , Missed or Changed Appointments . Any appointment changes or cancelations within less than 24 hours from the time of my a ppointment may be charged a $25 Fee. Rescheduling takes place at the discretion and availab ility of Miriam ' s Wel l Healing. This allows respect for myself , as well as the healing process I am pursuing and for Miriam ’ s Well Healing.

Client Signature:

Clear

Date:

Date

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

How would you rate your current sleep habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise to you participate in?

Please list any difficulties you experience with your appetite or eating patterns, including weight issues:

What, if any, health concerns are you currently receiving treatment or medication for?

What areas of your body tend to hold tension or stress?

Have you sustained any injuries (accidents, broken bones, etc.)? Did they require medical attention or surgery?

Do you have any chronic conditions, including pain?

Are you currently taking any prescription medication?

Please list medication and its purpose:

Are you receiving any other forms of treatment from holistic professionals? (E.g., acupuncture, herbs, homeopathy, supplements, nutrition program, etc.)

Have you ever been prescribed psychiatric medication?

Yes No

Please list and provide purpose and dates:

Date

Please provide purpose and dates:

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks or have any phobias?

If yes, when did you begin experiencing this?

Do you drink alcohol more than once a week?

Yes NO

How often do you engage recreational drug use?

Daily Weekly Monthly Infrequently Never

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

On a scale of 1 to 10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)

Alcohol/Substance Abuse

Yes No

Which Family Member?

Type a question

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Service Quality
Cleanliness
Responsiveness
Friendliness

Are you currently employed?

Yes No

If yes, name of your employer, and your position:

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief:

What do you consider some of your strengths?

What do you consider some of your weaknesses or traits would you like to change?

What are your goals in coming to see me?

I hereby affirm that I have answered all medical & psychological questions completely and honestly.

Client Signature:

Clear

Date:

Date