QRA New Client Intake Form

QRA New Client Intake Form

Please complete this before your first QRA session so we can identify priorities for your individualized support.
Please allow approximately 15–45 minutes to complete this intake form, depending on your health history and the amount of detail you choose to provide. Take your time and answer as thoroughly as you comfortably can. If you do not know an exact answer, simply provide your best estimate.

Important: This form does not save automatically. If you need to pause or leave the form, select Save at the bottom and have your private draft link emailed to you. Use that link to return without losing your answers.

Unsubmitted saved drafts are retained for up to two months.
Client Information
Legal Name

First NameMiddle NameLast Name
Preferred Name
Sex
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Marital / Relationship Status
Do you have children?
How many children do you have?
Anything else you would like to share about your children or family?
Referral Source
Referral details
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Concerns and Goals
Please describe up to three primary concerns. Include as much detail as you would like. Each concern should include how long it has been present, its current severity, and what you hope will change.
TOP CONCERN #1 - Describe your concern in as much detail as you would like
TOP CONCERN #1 - How long has it been present?
TOP CONCERN #1 - Current severity (1 Low-10 Highest severity)

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1 is 1, 10 is 10
TOP CONCERN #1 - What is your goal or what change would you like to experience?
Anything else you would like to add about Concern #1?
TOP CONCERN #2 - Describe your concern in as much detail as you would like
TOP CONCERN #2 - How long has it been present?
TOP CONCERN #2 - Current severity

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1 is 1, 10 is 10
TOP CONCERN #2 - What is your goal or what change would you like to experience?
Anything else you would like to add about Concern #2?
TOP CONCERN #3 - Describe your concern in as much detail as you would like
TOP CONCERN #3 - How long has it been present?
TOP CONCERN #3 - Current severity

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1 is 1 is Low Severity, 10 is 10 is Highest Severity
TOP CONCERN #3 - What is your goal or what change would you like to experience?
Anything else you would like to add about Concern #3?
Diagnosis and History
Current Physical Health Diagnoses or Conditions

Other
If you selected Other, please describe the physical health condition.
Past or Resolved Physical Health Diagnoses or Conditions

Other
If you selected Other, please describe the past or resolved physical health condition.
Physical health diagnosis notes, approximate diagnosis dates, current status, and anything else the client wants the practitioner to know.
Current Mental, Emotional, or Neurodevelopmental Diagnoses

Other
If you selected Other, please describe the mental, emotional, or neurodevelopmental condition.
Past or Resolved Mental, Emotional, or Neurodevelopmental Diagnoses

Other
If you selected Other, please describe the past or resolved mental, emotional, or neurodevelopmental condition.
Mental, emotional, or neurodevelopmental diagnosis notes, approximate diagnosis dates, current status, and anything else the client wants the practitioner to know.
Family Health History
What significant physical health conditions are present in your biological family?
What significant mental, emotional, neurodevelopmental, or substance-use conditions are present in your biological family?
Medications and Supplements
Current Medications: Name-Dosage-Duration-Reason
Please list all current medications, the dosage, how long you have taken each one, and the reason it is taken. Include birth control or other hormonal medications.
Current Supplements: Name/Brand-Dosage-Duration-Reason
Please list all current supplements, the brand, the dosage, how long you have taken each one, and the reason it is taken.
Recent Changes or Additional Medication and Supplement Notes
Current Symptoms
Energy symptoms

Other
Sleep symptoms

Other
Digestive symptoms

Other
Bowel symptoms

Other
Urinary symptoms

Other
Pain and neurological symptoms

Other
Respiratory and allergy symptoms

Other
Skin, hair, and nail symptoms

Other
Circulation and cardiovascular symptoms

Other
Mood and stress symptoms

Other
Hormonal and reproductive symptoms

Other
Additional comments
Dental history and current concerns

Other
Nutrition and Digestion
Diet Pattern

Other
Daily Water Intake (cups or ounces)
How often do you eat restaurant, takeout, or prepared food?
Recent Major Dietary Changes
Severe Food Allergies
List any diagnosed food allergies that may cause a serious reaction or require an EpiPen. Include the food and reaction.
Food Sensitivities or Intolerances
List foods that cause symptoms or are difficult to tolerate but do not require an EpiPen. Include the food and symptoms.
How often do you eat home-cooked meals?
Which cooking oils or fats are most often used in your home?

Other
Soda
Energy Drinks
Coffee
Other Caffeinated Beverages
Difficulty Swallowing

Other
Lifestyle and Environment
Exercise types

Other
Exercise frequency
Average hours of sleep
Typical Wake-Up Time

Hour Minutes

AM/PM Option
Typical bedtime

Hour Minutes

AM/PM Option
Additional sleep notes
Do you currently use, or have you previously used, any of the following?

Other
Use details
Alcohol Consumption
What type of alcohol do you usually drink?
Recreational substance use frequency
Details about recreational substance use
Environmental or occupational exposures
What is the primary source of the water you drink every day?
Additional notes on water
Please provide as much detail as you can. The more specific your answers are, the better I can understand your history, priorities, and how to support you during your QRA session.
What types of pets are in the home?

Other
WOMEN'S REPRODUCTIVE HEALTH - COMPLETE ONLY IF APPLICABLE.

If this section does not apply to you, please skip to the next section.
If this section does not apply to you, please skip to the next section.
Current reproductive status
Cycle status
Last menstrual period

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Currently taking hormonal contraception or hormone therapy?
Reproductive or hormonal symptoms

Other
History of hysterectomy or ovary removal
Any additional information you would like to share with your practitioner
Stress and Emotional Well-Being
Major life changes in the past 12 months

Other
Support or regulation practices

Other
Current stress level

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0 is No stress, 10 is Extreme stress
Relationship / marriage

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0 is No stress, 10 is Extreme stress
Family

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0 is No stress, 10 is Extreme stress
Work / business

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0 is No stress, 10 is Extreme stress
Finances

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0 is No stress, 10 is Extreme stress
Social / community

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0 is No stress, 10 is Extreme stress
Housing / home

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0 is No stress, 10 is Extreme stress
Caregiving

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0 is No stress, 10 is Extreme stress
Spiritual concerns

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0 is No stress, 10 is Extreme stress
Health

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0 is No stress, 10 is Extreme stress
Past trauma

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0 is No stress, 10 is Extreme stress
Grief / loss

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0 is No stress, 10 is Extreme stress
Commitment to Your Health Goals.
How much are you willing to change to work toward your health goals? Please answer honestly—there is no judgment.
Anything you would like to add about your readiness or possible barriers?
Final Required Downloads

Required for All QRA Clients
Download Your Scar, Trauma & Interference Field and Dental Chart

Choose the Interference field chart you feel most comfortable using. These options are provided for representation and ease of marking.

Download and print one chart. Complete both pages by marking the locations and possible dates (or years ago) of scars, injuries, burns, surgeries, broken bones, implants, dental work or other possible interference fields. Then upload the completed pages below.

Please complete the forms to the best of your ability. It is okay if you do not remember every detail—approximate dates or ages are fine.

Important: This form does not save automatically. If you need time to print and complete your chart, scroll to the bottom and select Save before leaving this page. Have your private draft link emailed to you or copy it somewhere safe. Return through that link to upload your completed chart and finish the intake form. Do not select Submit until your intake is completely finished.

If you experience difficulty uploading your completed chart—or if emailing it is easier—you may email it directly to info@healingbyreleasing.com

Please include your full name in the subject line so the chart can be matched with your intake form.

If submitting charts for more than one person, send each person’s charts in a separate email.

If you email your chart separately, you may submit this form once all other required sections are complete.
Female Scar, Trauma & Interference Field Chart - Lighter Skin Tone
Female Scar, Trauma & Interference Field Chart - Darker Skin Tone
Male Scar, Trauma & Interference Field Chart - Lighter Skin Tone
Male Scar, Trauma & Interference Field Chart - Darker Skin Tone
Dental Chart

Please download, complete, and upload the Dental History Chart. Do your best with the information you remember—it is okay if you do not know every detail or exact date.
Chart Uploads

Upload all completed charts below as well as most recent labs if you wish.
Upload Completed Body & Interference Field Chart

PDF or image files only.
Cancelof
Upload Completed Dental History Chart

PDF or image files only.
Cancelof
Upload Recent Laboratory Results (optional)

PDF or image files only.
Cancelof
Final Details
Final notes/comments you would like Arlena to know (Optional)
Accuracy Confirmation
Who is signing this form?
Client or Parent/Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Legal Guardian’s Legal Name

First NameLast Name
Relationship to Client
Should be Empty:

QRA New Client Intake Form

Client Information

Emergency Contact

Primary Concerns and Goals

Diagnosis and History

Family Health History

Medications and Supplements

Current Symptoms

Nutrition and Digestion

Lifestyle and Environment

WOMEN'S REPRODUCTIVE HEALTH - COMPLETE ONLY IF APPLICABLE.

Stress and Emotional Well-Being

Commitment to Your Health Goals.

Final Required Downloads

Dental Chart

Chart Uploads

Final Details