Ancient Way Healing

Ancient Way Healing

NEW CLIENT IN-TAKE FORM
Please be advised that we highly value your privacy, your personal information is kept private and confidential, any information provided below will never be shared without your express written consent unless your life is at serious risk of immediate danger.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Home Address*
This is particularly helpful for remote/long distance healing
Medical History

Pranic Energy Healing is a highly specific healing method, please carefully answer the following questions to the best of your ability, so that our practitioners can give you the best possible treatment for your ailments. We do not share your personal or private information with any individuals, companies, governmental departments or advertisers.
Q1: Please give a brief history of any significant or ongoing medical, psychological or spiritual issues that you wish to focus on in our work together.
Be as brief and clear as possible, we will have time to discuss this in greater detail during our appointment.
Q2: Do you smoke cigarettes? *
Q3: Do you, or have you ever, taken illicit drugs (including marijuana)?*
Q4: Do you drink alcohol? *
Q5: Do you have high blood pressure? *
Q6: Do you currently, or have you ever had cancer?*
Q7: Are you currently experiencing physical pain? (if your answer is yes, please provide details within your above answer to Q1)*
Q8: Are you currently experiencing emotional distress? (if your answer is yes, please provide details within your above answer to Q1)*
Q9: Are you, or could you possibly be pregnant?*
Q10: FOR IN PERSON PATIENTS ONLY Do you have any sensory sensitivities we need to know about (such as scents, bright lights, any allergies or particular sound triggers)
Please briefly detail any allergies or sensitivities in the space provided above
Q11: Do you have any pets?
Q12: Do you have cold or flu symptoms or a fever?
Client History
Have you experienced Pranic Energy Healing before?
If so, please briefly outline your experience above
Are you receiving any other medical, holistic or alternative healing treatments?*
Please briefly describe these treatments above.
Do you exercise regularly?*
Do you maintain healthy and balanced nutrition?*
Do you have a regular meditation or prayer practice?*
How many hours of sleep do you get most nights?*
How would you rate your life satisfaction level?*

1

2

3

4

5

6

7

8

9

10

1 is Not at all satisfied, 10 is GREAT!
Do you currently taken prescribed medications? *
If so, please provide details above
What do you hope to gain from Pranic Energy Healing?
How did you find Ancient Way Healing
ARE YOU TOTALLY COMMITTED TO HEALING ALL OF YOUR PHYSICAL, EMOTIONAL OR SPIRITUAL AILMENTS WITH ANCIENT WAY HEALING?*
Ancient Way Healing's Late Notice/Cancellation Policy

I understand that appointments must be cancelled more than 48 hours before the appointment time or else a fee will be incurred. A cancellation within 48 hours will incur a fee of $40.00, within 24 hours the cancellation fee is $65.00 and in the event of a no-show, no refund will be given for pre-paid appointments. For appointments that have not been prepaid you will be invoiced $75.00 as per our late notice/cancellation policy.
Indicate that you understand the information above by checking the box below:*

I understand Ancient Way Healing's late notice/cancellation policy
Ancient Way Healing Waiver
I,   First Name*   Last Name* understand that energy healing is a subtle form of therapy that is used to alleviate stress, help manage pain and increase deep relaxation. I understand that alternative therapies are intended to complement medical, psychological and physical treatments of all kinds. I understand that Ancient Way Healing cannot prescribe or perform medical treatment and that sessions are not intended to replace licensed medical professionals. I understand that Pranic Energy Healing practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional.

I understand that Ancient Way Healing and its practitioners are not responsible for my actions past, present or future. I understand that although this treatment has little to no risk of harm that John Gray and Ancient Way Healing are not responsible for any injuries or accidents that could possibly occur during treatment or within the treatment space.

(FOR DISTANCE PATIENTS): I, First Name   Last Nameunderstand that the practitioner will be remotely sending energy to me for the duration of my energy healing session(s).

First Name*   Last Name*        Date*
  Signature*
For patients under 18 years of age, the signature of a parent/guardian is required: I give consent forFirst Name   Last Name   to receive Pranic Energy Healing treatment.

Name of parent/guardian:   First Name   Last Name
Signature:   Signature
© All Rights Reserved. Created for Ancient Way Healing by Josephine King, 2023.
Should be Empty:

Medical History

Client History

Ancient Way Healing Waiver

© All Rights Reserved. Created for Ancient Way Healing by Josephine King, 2023.