Healing Consultation Form
Please fill out the following questions so that I can prepare the best healing session possible tailored for your needs.
Name
*
First Name
Last Name
Email
*
example@example.com
Please check the box below if you would like to receive a monthly newsletter sent via email from me.
*
Yes
No
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Name, address and contact number of GP:
*
Emergency Contact Name
*
Emergency Contact Number
*
-
Area Code
Phone Number
Have you had any accidents/ injuries or traumas that are still affecting you?
Are you taking any present medication, drugs or supplements? If you are, please state what you are currently taking.
Are you currently undertaking any other alternative therapies? If you are, please specify.
Have you undergone any recent surgeries or medical procedures? If you have, please provide details.
Do you have any allergies? If you do, please specify.
Is this your first experience of holistic healing?
Yes
No
What do you wish to gain from the healing session?
*
Imbalances within the body
Please provide either a yes or no answer to the following imbalances.
*
Rows
Yes
No
Appetite Loss/ Gain
Blood Pressure
Bowels
Diabetes
Digestion
Headaches/ Migraines
Hearing
Hormonal
Insomnia
Heart Condition
Muscular
Nervous System
Reproductive Organ
Respiratory
Skeletal
Urinary
Epilepsy
Are you disabled?
Do you smoke?
Consume excessive alcohol?
Are you or could you be pregnant?
High Temperature/ Fever
Infectious/ Contagious Disease
Recent Head/ Neck Injury
Recent Surgery
Fatal/ Terminal Condition
Recent Scar Tissue
Open Cuts/ Abrasion/ Severe Bruising
Skin Disorders
Undiagnosed Lumps/ Bumps/ Swelling
Botox
Corrective Surgery
Surgical Enhancements
Any other conditions that may affect the proposed treatment
Is GP referral required?
If you have any details you'd like to provide regarding any imbalances please write below...
Emotional and Mental Health
Please rate the degree of these frequencies (emotions) you are carrying in your body from 1-5 (5 being the highest).
Worry e.g. discontent, concerned, restless, worried
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Fear e.g. insecure, afraid, anxious, fearful, terrified
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Anger e.g. irritated, frustrated, annoyed, angry, explosive
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Sadness e.g. disappointed, upset, unhappy, sad, grieving
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Pre-tense e.g. coping, trapped, disheartened, depressed, lost hope
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
If you'd like to write any details about any of the above emotions you may be feeling or anything else that you feel I should know/ be aware of, please write below...
Holistic Treatment Consent
Please fill in and sign the following to ensure consent.
I understand that Reiki/ Crystal Healing/ Crystal Massage/ Angel Energy Healing is a holistic healing technique and is not a substitute for medical or psychiatric diagnosis and treatment. Please be aware that diagnosis is not given and medication is not prescribed. Ensure you continue to have regular medical check-ups as part of your overall health care plan with a qualified medical professional. Please inform your practitioner of any medical conditions, injuries, medications, pregnancy, or skin sensitivities. These therapies may need to be modified or avoided in cases of acute illness, severe psychiatric conditions, open wounds, or allergies. I consent to receive the holistic treatment from the practitioner named below.
*
I consent
Practitioner Full Name
*
First Name
Last Name
Description of Reiki Treatment: Reiki involves the gentle laying on of hands or non-touch energy transfer to facilitate relaxation, stress reduction, and overall well-being. The practitioner may place their hands lightly on or above various parts of the body to channel Reiki energy. The treatment may involve physical touch but will be conducted in a professional and respectful manner.
*
I consent
Description of Crystal Healing Treatment: Crystal Healing involves placing crystals on and around the clients body to restore energy balance and improve well-being. The practitioner may place their hands lightly on or above various parts of the body to channel the energy from the crystals. The treatment may involve physical touch but will be conducted in a professional and respectful manner.
*
I consent
Description of Crystal Massage: Crystal Massage uses carefully chosen crystals tailored to the client's mental, emotional, physical and spiritual needs to promote healing and enhance well-being. Gentle massage techniques are applied with light pressure on the client's face or body, while the practitioner holds the crystals in their hands to direct the energy to specific areas. The treatment includes physical touch, but it will always be carried out with professionalism and respect. Clients will remain fully clothed throughout the treatment.
*
I consent
Description of Angel Energy Healing: Angel Energy Healing is an intuitive energy session guided by Angelic presence to support the clients emotional, spiritual and energetic well-being. The practitioner may place their hands lightly on or above various parts of the body to channel the Angelic energy. The treatment includes physical touch, but it will always be carried out with professionalism and respect.
*
I consent
Benefits of Reiki: Reiki is believed to promote relaxation, reduce stress, alleviate pain, and enhance overall physical and emotional well-being. However, individual experiences may vary, and there are no guaranteed outcomes.
*
I consent
Benefits of Crystal Healing: Crystal Healing will aim to return your mind, body and emotions back to a harmonious, peaceful, joyous, loving state of being in accordance with a natural order of life. It can bring stagnant emotions to the surface for your attention to heal and possibly make you challenge outdated thought patterns that are contributing to negative traits and states of reality. It helps you to feel lighter, happier, balanced, relaxed, purified, connected as well as helping you to neutralise the mind by being fully present. However, individual experiences may vary, and there are no guaranteed outcomes.
*
I consent
Benefits of Crystal Massage: Crystal Massage can improve circulation by the gentle stimulatory effects of the crystal touching the skin, it helps people feel more connected, comforted and reassured, it helps to remove anxiety and stress, energetically the massage will lighten the area of the body providing a refreshing uplifted feeling, it helps to relax, release and tone muscles as well as slow down the aging process and it can be used to release excess energy and reduce pain. However, individual experiences may vary, and there are no guaranteed outcomes.
*
I consent
Benefits of Angel Energy Healing: Angel Healing can provide emotional clarity and comfort, deepens connection to spiritual guidance, clears energetic blockages and restores flow, supports healing of the heart and soul, reduces stress, anxiety, and energetic overwhelm, promotes peace, stillness, and inner calm as well as encourages spiritual growth and trust in the divine. However, individual experiences may vary, and there are no guaranteed outcomes.
*
I consent
Risks and Limitations: While Reiki, Crystal Healing, Crystal Massage and Angel Energy Healing are generally considered safe and non-invasive, it may not be suitable for everyone. Potential risks or limitations may include temporary discomfort, emotional release, or exacerbation of existing symptoms. It is important to communicate any discomfort or concerns during the treatment session.
*
I consent
Confidentiality: All information disclosed during the healing session will be kept confidential and will not be shared without your consent, except as required by law.
*
I consent
I have been advised that if I suspect I may have a medical condition, I should seek help from a qualified medical practitioner.
*
Yes
I have been advised that if I take any prescription drugs, I must first consult my GP/consultant before making any alterations.
*
Yes
I am over 16 years of age. The information I have given is true to the best of my knowledge and I have not withheld any relevant information.
*
I am over 16 years of age
I am under 16 years of age
The Practitioner has fully explained the holistic treatment and the procedures involved.
*
Yes
I understand that at all times, my personal body privacy will be maintained, I am not required to remove any clothing, except my shoes.
*
Yes
I confirm that the details given to me by the Practitioner are correct and that if any of my personal information changes, then I accept that I must inform the Practitioner accordingly.
*
Yes
I have had opportunity to ask questions regarding the above and I am willing to proceed with the treatment.
*
Yes
I understand that the fee per session has been discussed with my Practitioner.
*
Yes
Client Full Name
*
First Name
Last Name
Client Signature
*
Date Signed
*
-
Day
-
Month
Year
Date
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