New Earth Healing client information form
Customer Details:
Full Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Please take a new photograph specifically for this healing, clearly showing your eyes and the face.
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How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Have you experienced Kambo before?
Yes
No
More than once
Regularly
Do you have any contraindications that would prevent you receiving Kambo? (If you are currently having Any of these symptoms, please book a call with Neil to discuss further prior to booking.
Aneurysm
Blood clots
Brain haemorrhage
Stroke
Pregnant
heart conditions
undergoing chemotherapy or radiotherapy
psychosis
severe epilepsy
very low blood pressure
very high blood pressure
recovering from major surgery
taking the birth control pill
antibiotics
Other
Please list the medications you are currently on
Have you had any trauma in your life?
Yes
No
Please list any trauma you have experienced
School bullying
Physical abuse
Sexual abuse
Psychological abuse
Domestic violence
Childhood trauma
Violence
Witnessing violence or abuse of some kind
Accidents
Other
Please describe your trauma/s and how they effect your life today.
Please describe what may be going on in your life that I may need to know before we work together for this healing.
What is your current state of mental health? What would you rate your current stress levels (0/10) ?
Please summarise what pains, injuries, ailments, conditions, illness and/ disease, symptoms that you are currently dealing with.
How do you cope with stress?
What levels of support do you currently have from friends and family etc?
Have you had any Covid vaccinations
No
1
2
3
4
4+
Do you smoke/vape?
Yes
No
How many per day
1-5
6-10
11-20
20+
What causes you to smoke/vape?
Do you consume alcohol?
Yes
No
How often do you consume alcohol?
Daily
3 times a week
Only at weekends
every weekend
once a month
only on special occasions
What are the reasons for consuming alcohol
Any other drugs or substances that you use ?
Yes
No
Please list what you use and how often?
Type a question
Submit
Rate your sleep out of 10 and summarise
Rate your diet out of 10 and summarise
Rate your daily hydration out of 10 and summarise
Rate your exercise program out of 10 and summarise
Rate your ability to meditate out of 10 and summarise
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Rate the quality of your life out of 10 and summarise
As a human being, how would you rate yourself out of 10 and summarise
What traits do you want to change ?
What traits do you love about yourself?
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Before Kambo ceremony please fast for 12 hours, water only
Yes I understand
Please explain what you are coming into healing for ? What is it you want to let go of?
What is your desired outcome ?
During this session there may be times of physical touch, please describe any areas of the body which are a no go touch area ?
All sessions are recorded, for the safety of the client and facilitator . These recordings are personal between the facilitator and client. They are stored safely.
Yes I agree
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