New Client Information

EC with Cj

New Client Information

Please complete, sign and return this form as it is needed for session preparation
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Address (optional)
City*
State / Province*
Country*
Phone Number*

Area CodePhone Number
This number is my:*
Skype Name
E-mail*
Occupation
Spouse / Partner First Name & Age:*
List First Names / Ages of Siblings:*
List First Names / Ages of Children:*
Father:*

LivingDeceased
Mother*

LivingDeceased
HEALTH STATUS

Please complete all applicable sections
ILLNESS: check all that apply and provide additional details below:*

DOES NOT APPLY–I am not illillness was preceded by an accident, injury or some type of physical traumaillness was preceded by a traumatic event such as death, divorce, bankruptcy, foreclosure, etc.have received a medical diagnosiscurrently under medical care / receiving medical treatment(s)currently doing alternative healing treatment(s) for this condition
ILLNESS DETAILS: history, diagnosis, treatment, medications, supplements, alternative treatments, etc.
PHYSICAL PAIN: please check all that apply and provide additional details below:*

DOES NOT APPLY–I am not in painpain was precipitated by a physical cause such as an accident or injurypain was precipitated by a traumatic event (death, divorce, etc)have had medical treatment / currently under medical carehave received a medical diagnosis related to pain conditioncurrently taking pain medicationcurrently doing alternative pain management / treatment
PHYSICAL PAIN DETAILS: when it started, location, treatment(s) received, etc.
PAIN LEVEL: If your pain fluctuates, indicate both low and high levels:

Level 1 (very mild; barely noticeable; rarely think about it))Level 2 (minor; annoying; occasional stronger twinges)Level 3 (noticeable & distracting, however mostly tolerable))Level 4 (moderate; can be ignored for periods of time, but still distracting)Level 5 (moderately strong; can't be ignored more than a few minutes, but still able to work and participate in some activities)Level 6 (moderately strong; interferes with normal daily activities; concentration is difficult)Level 7 (severe; dominates senses and limits ability to perform normal daily activities; interferes with sleep)Level 8 (intense; physical activity severely limited; conversing requires great effort)Level 9 (excruciating; unable to converse; moaning / crying out)Level 10 (unspeakable; unimaginable; bedridden and possibly delirious)
EMOTIONAL PAIN: check all that consistently have a negative impact on your emotional wellbeing (make note below of any emotional issues not listed here):

DOES NOT APPLY–I am not in emotional painanger (with self or others)abuse / trauma (past or current)addictionanxiety / panic attacksdepressioneating disorderfeelings of grief, sorrow, lossfeelings of worthlessness, unworthy, low self-esteemfeelings of loneliness and isolationplagued by negative thoughts and feelings about self
EMOTIONAL PAIN DETAILS: (any diagnosis, treatment, medication, history, etc)
EMOTIONAL SENSITIVITY: check all that apply*

I often feel the emotions or pain of others, especially those close to meI often focus more on the needs of others than on my ownI feel very uncomfortable / overwhelmed in crowded placesI often feel ungrounded (e.g. spacey or dizzy, difficulty focusing / completing tasks, easily distracted, etc )When I see or read about cruelty and violence in the news or in books, movies, etc. it's nearly unbearableI enjoy / need lots of alone timePeople (even complete strangers) often confide in me about their problems, worries, etc.I feel rejuvenated in nature and have a strong connection with animalsI'm good at knowing or predicting things about people and situationsI often feel like I'm on an emotional roller coasterIf I'm around an angry, depressed or sick person I feel weighed down with negative emotionI sense the energy around people, animals or even placesI often have inexplicable aches and painsI often feel responsible for how others treat me and for anything that goes wrong in my relationshipsI can usually tell when someone isn't being truthfulI'm creative and have an active imaginationI'm easily distracted when I have to do things I don't likeI struggle to relax when in the company of people I don't know wellI'm sensitive to sounds, smells, bright lights and certain fabricsI often feel fatigued, especially after spending time with certain peopleI've always felt 'different', like an outsider who doesn't really fit inNONE OF THESE APPLY TO ME
EMOTIONAL SENSITIVITY DETAILS: any details you care to share about how emotional sensitivity impacts your life
ADVERSE CHILDHOOD EXPERIENCES
Pleases indicate any of the following situations you experienced prior to your 18th birthday (click all that apply):

A parent or other adult in the house often swore at me, insulted me, put me down, humiliated me, bullied me or in some other way made me fearful that I'd be physically hurt.A parent or other adult in the house often pushed me, grabbed me, slapped me, threw things at me, or hit me so hard I had marks or was injured.A parent, other adult, or someone at least 5 years older touched me, fondled me, attempted or actually had oral, anal or vaginal intercourse with me, and / or they had me touch or fondle them in a sexual way.I often felt that no one in my family loved me or thought I was important or special, and / or I felt that my family didn't look out for each other, feel close to each other, or support each other.I often felt I didn't have enough to eat, had to wear dirty clothes, and had no one to protect me; OR my parents or caregivers were too drunk or high to take care of me or take me to the doctor if needed.I lost a parent through divorce, abandonment or for another reason.My mother or stepmother was often pushed, grabbed, slapped or had things thrown at her; OR she was bitten, hit with a fist or something else hard; OR repeatedly hit over several minutes or threatened with a gun or knife.I lived with someone who was a problem drinker, alcoholic or used street drugs.A household member was depressed, mentally ill or attempted suicide.A household member went to prison.
Do you have specific healing goals or expectations? *
What do you want to work on in your first session?*
Have you ever had any type of energy healing (e.g. Reiki, acupuncture, therapeutic massage, etc.)?*

YesNo
If yes, any detail you care to share about the experience, effectiveness, etc.:
How did you hear about me?*

Healers LibraryWorkshopReferralOther
Name of person who referred you, or any details about how you found me:
CLIENT INSTRUCTIONS:
At least 24 hours prior to your session:
1. Complete and e-sign this form
2. Send a photo of yourself (selfies are fine!) to cj@cjhathaway.com. This is not required but it helps me make a strong connection with you.
During your session:
- If you chose an EMAIL Distance Healing Session, you will not be physically present for the session – I make an energetic connection to you (similar to a wireless connection) and work with your Higher Self during the session, after which you'll receive an email with notes about the session
- If you chose a PHONE Distance Healing Session, you will be present with me on the phone during your session
- Some people report feeling tired after a session - honor your body's need for extra rest
- Relax and be open to healing!
After your session:
- Drink plenty of water and eat healthy food–this helps your body expel negative energy.
- Baths with Epsom or Himalayan salt can help draw out the energies we released in the session. If you're unable to take a full bath, soaking your feet in salt water is also beneficial.
- Strenuous activities are generally not recommended for at least 24 hours after a session.
- Remember, clearing negative energy from your body is a form of detox so allow your body time to process the release. Please note that during processing some people feel more tired than usual, have vivid dreams or interupted sleep patterns, or re-experience some of the emotions released as they leave the body. A small percentage of people may also experience flu-like symptoms. These are all normal.
- Should you have questions either before of after your session, you can either email me or set up a FREE 30-minute consult call.
Initial here to indicate you're read, understand and agree to the above instructions:*
Agreement and Consent:

I understand that CJ Hathaway uses various energy healing modalities and techniques intended to support physical, mental, emotional and spiritual balance, thus supporting your innate self-healing abilities, and I agree to receive these services.

I understand these services are not a substitute for medical care and that any information, advice or coaching I receive from CJ Hathaway is not intended to replace any treatments, prescriptions or diagnoses by medical professionals for physical or mental conditions or illnesses.

I further understand that CJ Hathaway makes no guarantees or promises of healing or recovery from any current or future illnesses or conditions.

I accept responsibility for my own healing.

I agree to communicate any questions or concerns I may have in a timely manner.

I understand that while information from my sessions is confidential, details about my results may be anonymously shared (only initials and state or country are shared) for the purpose of promoting CJ Hathaway's services.

I fully consent to my participation in CJ Hathaway's energy healing services as outlined, hold her harmless, and understand she accepts no liabilities of any kind.

My electronic signature below signifies that I have read, understand and agree to all information, terms and conditions outlined in this form.
Initial here to indicate you've read, understand and agree to 'Agreement and Consent' section:*
Signature Required: (on a computer use your mouse to sign; on a mobile device use your finger to sign)

Clear
Would you like to be added to my mailing list for newsletters and periodic updates?*

YesNo
Today's date:*
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EC with Cj