DRAGON ENERGY HEALING
Holistic Energy Healing - Client Information
Name
*
Full Name
Date of birth
*
/
Day
/
Month
Year
Gender
*
Assigned at birth
Species
*
Human, Dog, Cat, Horse etc
Email
*
Phone Number
Please enter a valid phone number.
Occupation
*
Country of Residence
*
How did you hear about me?
Focus Issues
Fill out the fields below, choosing the most problematic issues and rating them from 1 to 10, based on your average daily, weekly or monthly experience. A one is most minor, a ten is most severe.
1.
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Rating
0 = Nil 10 = Extreme
How long has this been going on?
2.
*
Rating
0 = Nil 10 = Extreme
How long has this been going on?
3.
*
Rating
0 = Nil 10 = Extreme
How long has this been going on?
4.
Rating
0 = Nil 10 = Extreme
How long has this been going on?
5.
Rating
0 = Nil 10 = Extreme
How long has this been going on?
Did your family situation while growing up relate to any/all of these issues? How?
What (if anything) triggered the onset of any of these problems?
Are there any experiences you feel may be related to any of these issues, even indirectly?
Please list any family members or partners who have or have had similar issues
Please describe anything else that may be pertinent or useful to know
Preference:
Emotion Code
Body Code
Belief Code
Unsure
Please upload a recent photo of yourself.
*
Browse Files
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This helps me to form an energetic connection with you during our session.
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Client Signature
*
Are you ready and willing to allow for change in your life? Are you ready to take that step forward and let go of what is hindering a life full of peace, joy and grace?
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