Therapy Application

Full Name

First NameMiddle NameLast Name

Phone Number/Whatsapp

Please enter a valid phone number.

City/State

Hebrew Name (if you have one)

For example: Chaya bat Eliana Leah

Best way to reach you:

EmailTextWhatsappOther

Email

example@example.com

Birthdate and time of day (if known)

For example: "8/24/89 afternoon" or "8/24/89 3PM"

Hebrew Birthday (if you know)

For example: 12 Tishrei

Are you employed? What type of work do you do?

Level of Torah observance or affiliation:

Are you named after someone? --This is a very important question-- If so, please take between 1-3 sentences to describe what you know about this person.

Marital Status

Do you have any children/stepchildren children? If so, what are their genders and ages?

Are your parents alive? If not, how long ago did they pass away?

Do you have siblings? What are their ages and genders?

If married: How long and which number marriage is it?

Have you ever been diagnosed with any medical/emotional/mental issues by your doctor? Any operations or hospitalizations in the past? Please provide details of your diagnosis including when you were diagnosed.

Do you have any particular traumatic event you would like to mention? If so, please include age and details.

How would you define your emotional state right now?

Are you taking any regular medication or supplements? Please list their names and dosage.

Do you know of any vitamin or mineral deficiency? YES/NO

Have you had counseling previously, alternative intervention, or medical treatment regarding the issues you are seeking help with? Please provide details.

What motivates you to create the changes you're looking for in your life?

Do you have support from friends and family?

YesNoI haven't asked for help

How do you practice self-care care?

How familiar are you with Energy therapy?

Previously usedVaguely knowNo knowledgeOther

Is there anything else you would like to share?

Why have you decided to seek assistance & what would you like to discover about yourself through these sessions? Please specify 2 major areas/issues you wish to get help in and IY'H see a change.

What is your favorite color?

Pick up to 3 gemstones from the picture above, and list them below. (Don't overthink it, just pick what you like.)

How did you hear about Torah Energy?

Please upload a picture of yourself from the last 2 weeks. You should be facing the camera and the only one in the picture.

Have you been vaccinated for COVID?

YesNoYes & Boosted onceYes & Boosted multiple times

Therapy Application

Please choose up to 3 gemstones