New Client Form

Welcome!

Thank you for taking time to complete the form below. Answering these questions will allow me to better understand why you are here and how I can best serve you as a Healing Practitioner. If you are unable to answer any question/s simply write N/A in the space provided.
New Client Form

Energy Alchemy with Minqwa
Personal Details:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Email*
example@example.com
Phone Number*
Emergency Contact Name*
Emergency Contact Phone Number*
How Did You Hear About Us? (Please include client name if referral)*
Have You Experienced Any Energy Healing Before?*
Clarity Questions:
From the following options, tick 5 areas that you are seeking relief, clarity, or healing?*

Reduce Physical Pain, Tension, and StressImprove Posture and FlexibilityReduce Mental Chatter and OverthinkingWork Goals/Performance/BlocksLife Goals/Performance?BlocksImprove Sleep QualityRelease Repressed EmotionsStrengthen The Mind, Body, Soul ConnectionStrengthen IntuitionGain Clarity and MeaningNegative Energy ReleaseKarmic Cords and Ancestral HealingForgive and Release The PastRelationship ChallengesFind passion and purpose in lifeMental Patterns & HabitsEmotional SensitivitiesBoundariesMind Body Connection
List 1-5 main reasons for your visit in your own words:*
What type of practitioners and health care providers have you consulted in the past and how helpful have they been?*
Who do you currently have on your health team and how long have you been seeing them for? (i.e. Naturopath, Nutritionist, Psychologist, Life Coach etc.)
Is there a particular modality you have booked in for?

KinesiologySpinal EnergeticsAngelic healingLight languageBrain GymReikiAncestral, Karmic HealingSpace/home healingNo
If you partake in any of the following activities, tick them below:

YogaPilatesMeditationBreathworkPersonal TrainingGym, Including ClassesWalkingRunningCyclingSwimming
List ant activities that you enjoy that haven't been listed above:
Physical Questions
Describe any significant current and past history concerning your physical body: (include any accidents, medical interventions, medications, symptoms, toxin or drug exposure, if you ever been unconscious)*
Do you take any medication or supplements? Please list any medication you are currently taking.*
Do you smoke and or consume alcohol?
Do you or have you used recreational drugs? *
How would you rate your overall physical health?

PoorOkayGoodVery GoodExcellent
If you have any current or reoccurring physical pain in your body, list them below and rate the levels of pain from 1-10:
What does the pain feel like:

SharpDull AcheBurningPins and NeedlesNumbnessStiffnessConstantIntermittentWeakness
Mindful Questions:
Describe any significant past history concerning your mental and emotional life : (include any major life stressed, traumas or events, as well as any medications or emotional & mental symptoms)*
How is your mental and emotional life presently? *
On a scale from 1-10, how would you rate your sleep? Do you have trouble falling asleep and/or stay asleep?
What would your main goal/s for the future be for your physical, mental, and emotional life?
Is there any other information that you feel may be relevant to your care at Living Is A Practice that has not been covered?*
I offer a multidisciplinary practice, and adapt sessions according to what is suitable for your safely and wellbeing.

Therefore please check the list of conditions which are not suitable for Spinal Energetics.

For your own safety and wellbeing it is important that you are completely honest about your mental and physical state.

- Current Diagnosed Severe PTSD or complex PTSD

- Severe Mental Health Conditions (bipolar, schizophrenia, psychosis).

- Currently taking heavy medication that alters the brain chemistry. (anti-depressant, anti-anxiety, antipsychotic).

- Recent physical injuries, fractures and surgeries (at least 6 months post surgery)

- Brain Trauma

- Epilepsy

- History of diagnosis of aneurysms

- Cardiovascular Problems

- History of Seizures

- Severe Asthma

- Heart Disease

- Heart Conditions

- Hospitalisation for psychiatric conditions, emotional crisis etc within the past 3 years.

- Pregnancy/Breastfeeding

- Over the age of 70

- Any other medical, psychiatric or physical conditions that would impair or affect your ability to engage in activities involving intense physical and emotional release.

If there are any other conditions or concerns that raise alarm please let me know before your appointment.
I confirm that I have read and understood all the conditions listed above and do not have any of the mentioned conditions. If I have already discussed any of these with Minqwa, I acknowledge that it is okay to proceed with ticking this box.*

I Agree
I give consent to receiving a treatment in the form of Spinal Energetics, TFH Kinesiology and Intuitive Energy Healing.*

I Agree
I agree to be contacted by phone, WhatsApp, and email for updates, scheduling, and communication related to my sessions. If you prefer not to be contacted through any of these methods, please let me know your preferred form of communication.*

I Agree
I give permission for my session to be filmed or recorded for educational, promotional, or social media purposes. I understand that I will be informed beforehand if any filming will take place and have the right to decline.*

I Agree
Confidentiality

We take confidentiality very seriously at Living Is A Practice and in line with GDPR (ICO No. ZB155293). Your responses will be kept confidential and the information will only be used for the sole purpose of Living is a Practice.
By signing this form I am confirming I have carefully reviewed the information above and assure you that my responses in this form are genuine and truthful. I understand an Healing Practitioner does not give any medical diagnosis or treatment but do correct energetic imbalances and encourage your body's natural healing. Fees are non-refundable. please ensure 48 hours notice if you needed to reschedule or cancel appointment, full fee will be taken with less than 48 hours notice. Thank you *

Clear
Should be Empty:

Welcome!

New Client Form

Personal Details:

Clarity Questions:

Physical Questions

Mindful Questions:

Confidentiality