Client Intake Form for Healing

Client Intake Form for Healing

CONFIDENTIAL
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-mail
example@example.com
Mobile Phone

Country CodeArea CodePhone Number
Country of Residence
Birth Date

MonthDayYear
Who recommended you? How did you find out about us?
How can we help you? Please mention reasons for enrolling into our program.
Who is your healing specialist?
Personal Information
Marital Status
No. of children, if any
Employment status
Occupation/Career
Name of employer, if applicable
Tell us about your Overall Health and Habits
Do you consume
Does your diet include

Other
Specify any recreational or prescription drugs you are taking here
Do you have any allergies? If so, please specify what allergies you have.
How often do you exercise?
What exercise/s do you do?
What is your weight goal?
My current weight is:
Height
Physical Health Status

Other

Total Health Status - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)

Rows	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Physical Health
Vitality and Energy Level
Emotional Stability
Mental Attitude and Clarity
Religious/Spiritual/Inner Alignment

General Quality of Life - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)

Rows	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent	N/A
Relationships at Home
Relationships at Work
Social Relationships
Job/Role Satisfaction
Quality of Rest/Relaxation
Ability to Manage Stress
Quality and Time for Recreation
Financial/Material Life
Level of Success
Level of Self-Fulfillment in Life

Psychological Status

Rows	Yes	No
Fear/Phobia
Anger/Frustration
Anxiety/Worry
Sadness/Loneliness/Grief
Guilt/Self-Pity
Resentment/Pent-up Emotions
Lack of Self-Confidence/Self-Esteem
Laziness
Lack of Motivation/Purpose
Slowness in Action/Indecisiveness
Psychological Depression
Suicidal Tendency
Self-Destructive Behavior
Anti-Social/Oppositional Tendency
Vice/Addiction
Compulsion/Obsession
Trauma/Post-Traumatic Issues
Shame
Abused/Victim
Abuser

Please describe any other psychological issues you may have or give additional information related to the items you have checked above.
Have you had COVID-19 Infection?
Date of infection/exposure (if known):
Date when symptoms started:
Date of Positive COVID-19 test:
Name of attending physician:
Name of cilnic/hospital of testing or confinement:
Date of related hospitalization if any:
COVID-19 Symptoms Experienced
Please choose your preferred service:

Other
Please upload your recent picture

Full body picture is preferable
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DISCLAIMER/WAIVER I understand that World Institute for Incurable Diseases (WIID)TM, Wisdom Institute for Leadership and Global Advancement (WILGA)TM, BElife Institute for Higher Consciousness (BIHC)TM, MDP BElife and MDP Village programs do not claim to supplant or replace medical or psychological treatment. I understand that WIID, WILGA, BIHC and MDP Village specialists and services do not diagnose any health or psychological conditions. I hereby forever release and hold World Institute for Incurable Diseases (WIID)TM, Wisdom Institute for Leadership and Global Advancement (WILGA)TM, BElife Institute for Higher Consciousness (BIHC)TM, MDP Village, MDP BElife, Master Del Pe and all of its officers, agents, employees, directors, executives, managers, successors and licensees harmless from any and all liability, encumbrances or responsibility for the outcomes of services provided. Everything I have written and answered is true and correct.
Signature

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Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Intake Form for Healing

Personal Information

Tell us about your Overall Health and Habits