Client Information Form

Client Information Form
Name *

First Name Last Name
Today's Date

Month Day Year
Date
Email *
example@example.com
Phone Number

Country Code Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Time Zone

Eastern Central Mountain Pacific
Birth Date

Month Day Year
Date
Current Age
Marital Status
Spiritual Preference
Children and Ages

Health & LIFE Questionnaire

Please provide an answer to each question below
1. Share current health problems or concerns
2. Are you under doctor’s care for health concerns now? Yes or No. If yes, please provide a brief description
3. Do you currently use an Alternative Health Modality ie: Acupuncture, Chiropractic, Massage Therapy, or other energy healing technique to improve your health or other life issues?
4. Please list any Alternative Health Modalities used in the past.

Rank & Rating Top Health or Life Issues to Improve

Prioritize & Rate each on a Scale of 1 to 10 of how it feels to you currently (10 = very severe)
#1
Rate Level
#2
Rate Level
#3
Rate Level
#4
Rate Level
#5
Rate Level

Major Life Traumas or Events

What major life traumas have you had (if any)? Please provide a brief summary. You may add more than 3 as needed. Examples are injuries or other significant health problems, experiencing the divorce of your parents or of your own marriage, childhood traumas, etc.
#1
Age at Event
#2
Age at Event
#3
Age at Event
Final Questions
Are there any other concerns you’d like me to be aware of before we begin?
Are you motivated to get well or to see improvements in your health & life?
What are your main goals that you’d like to see improve by our working together?
Note: Releasing trapped emotions using The Emotion Code, or any other type of Energy Healing practiced by Joy Harris, whether in person or by proxy, is not a substitute for medical care. This information is not intended as medical advice and should not be used for medical diagnosis or treatment. Information given to you on this site or in any session obtained on this site is not intended to create any physician-patient relationship, nor should it be considered a replacement for consultation with a healthcare professional. If you have questions or concerns about your health, please contact your healthcare provider. Energy Healing promotes harmony and balance within, relieving stress and supporting the body’s natural ability to heal. Energy healing is widely recognized as a valuable and effective complement to conventional medical care. After completing your first session if you believe that you have not benefited or received any value whatsoever, your fee will be promptly refunded if we are notified in a timely manner. 1. Healing sessions are strictly confidential. 2. Your personal information will never be shared with anyone. We make no claims as to healing or recovery from any illness. This information is offered as a service and is not meant to replace any medical treatment. No guarantee is made towards validity. Use this information at your own risk. By viewing or using Joyful Energy Heals website, you consent in the event of a dispute or disagreement, to the exclusive jurisdiction and venue of a court of competent jurisdiction in New Mexico and to the exclusive use of the laws of the State of New Mexico
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Client Information Form

Health & LIFE Questionnaire

Rank & Rating Top Health or Life Issues to Improve

Major Life Traumas or Events

Final Questions