Dragon Energy Healing
Emotion Code® & Body Code™ - Client Information
Name
*
Date of birth
*
/
Day
/
Month
Year
Phone
Email
*
Occupation
Family History:
Relationship Status
*
Single
Defacto/Married
Divorced/Separated
Widow
Mother
*
Alive
Deceased
Unknown
Father
*
Alive
Deceased
Unknown
Were you adopted?
*
No. of siblings(Female)
*
No. of siblings (Male)
*
No. of children?
*
No. of grandchildren?
*
You have the choice of what would like to focus on in the sessions.
Examples of issues we can focus on in a session include (but is not limited to):
Focus Issues
What is of the most concern for you right now? List any symptoms that you are experiencing with each issue. How would you rate the impact of this issue? How often does this issue occur?
1.
*
If nothing specific comes to mind, just type: General
Rating
0 = Nil 10 = Extreme
Frequency
Please Select
Daily
Weekly
Monthly
Rarely
2.
Rating
0 = Nil 10 = Extreme
Frequency
Please Select
Daily
Weekly
Monthly
Rarely
3.
Rating
0 = Nil 10 = Extreme
Frequency
Please Select
Daily
Weekly
Monthly
Rarely
is there more information you would like add regarding the above?
Please upload a recent photo of yourself.
*
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This helps me to form an energetic connection with you during our session.
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Client Signature
Clear
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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