Living is a Practice New Client Form

Welcome!
Welcome and thank you for being here.

This New Client Form is an invitation to check in with yourself and feel whether now is the right time, and whether I'm the right guide for your journey.

Please fill this in mindfully and honestly, it helps us both begin from a place of clarity and mutual respect. There’s no rush to complete it.

When you're ready, tune in and let your answers come from within.

I work intuitively with energy, body, and spirit to support release, realignment, and remembrance. My approach is not for everyone and that’s okay.

Some of the questions below include details about your physical and emotional well-being, which help me ensure your safety and tailor our sessions with care.
Let's Begin
Personal Details:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-binaryTransgender
Pronouns*

He/HimShe/HerThey/Them
Email*
example@example.com
Phone Number*
Emergency Contact Name*
Emergency Contact Phone Number*
Feeling Into Alignment
What called you to reach out now?*
What are you moving through or noticing in your life that you'd like support with?*
Have you worked with energy, somatic, or intuitive healing before? single select

YesNoA little, but I'm curiousI'm not sure what counts
What healing or support modalities have you tried (if any)? multiple select*

Talking therapyReikiSomatic/bodyworkBreathworkKinesiologySpinal EnergeticsCranial SacralPhysiotheapyMassageIntegrated Energy TherapyBrain GymNone of the aboveOther
If you chose 'other', please share
Healing Intention & Self-Awareness
How do you currently relate to your own healing journey?(There’s no right answer, this is simply for reflection.) single select

I feel ready to be guided and take part in my own healingI’m curious but unsure what I needI often look for others to tell me what’s wrong or fix things for meI’m still figuring out how to relate to healing
Is there anything else you’d like to share about your relationship with your own growth or healing?
Your Body & Medical History

This information is confidential and helps me ensure our work together is appropriate and supportive for your system. Please only share what feels relevant and comfortable, it's here to help me hold the space safely and responsibly.
Are you currently taking any prescribed medication or undergoing any medical treatment? (This helps me understand how best to support you in a safe and respectful way. No need to go into depth, just what feels relevant.)*
Have you experienced any injuries, surgeries, or long-term physical conditions that might be relevant to energy or body-based work?*
Do you have a history of any of the following?multiple select*

PTSD or complex traumaAnxiety or depressionPanic attacksNeurological conditions (e.g. epilepsy, seizures, MS)Heart Conditions (e.g. arrhythmia, murmur, pacemaker, etc.)Seizures (past or present)History of DissociationHigh or low blood pressureSensory Processing SensitivitiesHistory of head injury or concussionRecent childbirth or pregnancyNone of the aboveOther
If you chose ‘other’, please specify
Is there anything else about your body, health, or past experiences you feel is important for me to know before we begin?
Lifestyle & Wellbeing
Do you currently use or regularly engage with any of the following?(Please tick all that apply)*

AlcoholCigarettesCannabisOther recreational drugsVapingCaffeineNone of the above
If you'd like to share any details about how this affects you or your healing journey, please do so here:
Do you currently practice or engage in any of the following activities to support your well-being?(Please tick all that apply)*

WalkingRunningGym / Fitness trainingYogaDance or movementSinging / MusicCreative expression (art, journaling, etc.)Meditation / BreathworkSwimmingOther
If 'other' please share
Practical Bits
Are you interested in: multiple select

In-person sessions in LondonOnline sessionsGroup sessions or eventsNot sure yet
How did you find me?Multiple Select

InstagramTikTokWebsiteReferral from someoneWord of mouthOther
Other (please specify below)
Final Check-In
In your own words, what would you love to receive or experience through this work together?*
Is there anything else you’d like to share, ask, or clarify before we begin?*
Consent & Agreement
I offer a multidisciplinary energy-based practice, drawing on modalities including Spinal Energetics, Kinesiology, Brain Gym, Reiki, Light Language, and intuitive healing.

Sessions are tailored to your needs and guided by what best supports your safety and well-being.

Please note that Spinal Energetics and other energy-based modalities may not be suitable if you are currently experiencing or have a recent history of:

- Current Diagnosed Severe PTSD or complex PTSD

- Severe Mental Health Conditions (bipolar, schizophrenia, psychosis).

- Currently taking heavy medication that alters the brain chemistry. (anti-depressant, anti-anxiety, antipsychotic).

- Recent physical injuries, fractures and surgeries (at least 6 months post surgery)

- Brain Trauma

- Epilepsy

- History of diagnosis of aneurysms

- Cardiovascular Problems

- History of Seizures

- Severe Asthma

- Heart Disease

- Heart Conditions

- Hospitalisation for psychiatric conditions, emotional crisis etc within the past 3 years.

- Pregnancy/Breastfeeding

- Over the age of 70

- Any other medical, psychiatric or physical conditions that would impair or affect your ability to engage in activities involving intense physical and emotional release.

It is essential that you are honest about your mental, emotional, and physical state so I can ensure your session is supportive and appropriate.

If there are any other conditions or concerns that raise alarm please let me know before your appointment.
I confirm that I have read and understood the above and that none of the above apply, or that I have disclosed them fully.*

I Agree
By submitting this form, you acknowledge and agree to the following:

The services provided are complementary in nature and do not replace medical or psychological care from licensed professionals.

You remain fully responsible for your own health and well-being throughout our work together.

All information shared will be treated with strict confidentiality and handled in accordance with GDPR guidelines. Your personal data will only be used in relation to your sessions and will never be shared or sold. You may request access to or deletion of your data at any time.

Communication Consent

I agree to be contacted via phone, WhatsApp, and email for updates, scheduling, and communication related to my sessions. If you prefer not to be contacted through one or more of these methods, please inform me of your preferred communication channel.

Media Consent

I give permission for my session to be filmed or recorded for educational, promotional, or social media purposes. I understand I will be informed in advance if any recording is planned and that I have the right to decline participation in any media content.

By signing this form, I confirm that:

I have carefully reviewed and understood the above information. My responses are truthful and accurate to the best of my knowledge.

I understand that a Healing Practitioner does not diagnose or treat medical conditions, but works to correct energetic imbalances and support the body’s natural healing process.

By entering my health details, I explicitly consent to my health questionnaire, including any information about my physical and mental health, being processed by Minh-hoa Dang (Minqwa), trading as Living Is A Practice, for the purpose of ensuring my safety during the provision of holistic energy services.

Cancellation Policy

Please provide at least 48 hours’ notice if you need to cancel or reschedule an appointment. Cancellations with less than 48 hours’ notice will incur the full session fee.

Thank you for your understanding.
Clear
Feeling Into Alignment
Should be Empty:

Welcome!

Let's Begin

Personal Details:

Feeling Into Alignment

Healing Intention & Self-Awareness

Your Body & Medical History

Lifestyle & Wellbeing

Practical Bits

Final Check-In

Consent & Agreement

Feeling Into Alignment