Client Information Form

Client Information Form
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name

First NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Occupation
Marital status
Nationality
Referred by (if applicable)
Have you ever undergone any type of healing or therapy before? Please give brief details.
Do you currently have any emotional or physical concerns?
Are you pregnant? If yes, which trimester are you in?
Please list medication, if any, that you are currently prescribed.
Have you ever undergone treatemnt for Bipolar, Schizophrenia or Epilepsy?
What are your expectations from this therapy?
Delaration

I understand that I am receiving healing therapy of my own free will. I fully understand what my therapist has explained about the process and that the results of this healing are not guaranteed and differ from person to person. Much of this depends on various factors including mental and psychic receptivity of a person towards the healing process.
Client signature
Should be Empty: