Intake Form

Intake Consent Form

This Intake and Consent Form has been given to you to provide valuable information in assisting your therapy. While sharing most information in this Form is voluntary, you must fill out the contact information immediately below, for us to work with you.

If you have any questions about how to complete this form, how we use your information, or what your rights are regarding your information, please ask your practitioner immediately.

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Date

MM slash DD slash YYYY

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Code of Ethics(Required)

Empowerment of Healing LLC Code of Ethics 1) Preserve client confidentiality, and never share information learned during sessions with others or intake information unless required by law. 2) Abstain from giving any medical diagnoses, interfering with the treatment of a licensed health care provider, or suggesting the use or change of use of any prescription, medication, or treatment. 3) Continue the process of enhancing my professional qualifications, training, experience and skills through ongoing education and research of new and existing energy techniques to benefit mind, body and spirit healing and maintenance. 4) As the practitioner I will always be responsible for the energy I bring into the session space be it in person or distance. I will always strive to be positive. 5) Respect and value all energy workers and types of therapy modalities, and refrain from making negative statements about others. 6) Encourage my clients to learn to heal themselves and assist them in their personal growth. 7) Treat my clients and their physical person with the greatest respect, and never engage in any illegal or immoral activity which hurts them, such as unsolicited touching of their genital area or breasts, asking them to disrobe, or sexual comments, jokes or references. 8) Abstain from the use of drugs or alcohol during all professional activities. 9) Educate my clients regarding the merit of energy healing therapy in conjunction with other medical treatments, and thoroughly explain that it does not guarantee a cure and is not a substitute for medical or psychological treatment, and only a supplement to these treatments. 10) Learn and obey the most current local, state, and federal laws applicable to my practice. 11) Be truthful in my advertising by openly discussing my training and background, what is offered in the type of session selected, the fee that is charged, and the amount of time spent in a session.

I read the Code of Ethics

Client Acknowledgment and Consent to Receive Services(Required)

Practitioner Commitment in Providing Services The Disclosures made here are accurate to the best of my knowledge and reflect my commitment to your therapy as my client. I will at all times endeavor to abide by the Code of Ethics I have adopted for myself. I will work with you in your energy therapy to reach the goals you have set for yourself and will not interfere with your own personal beliefs or energy efforts. If at any time I feel it necessary or advisable, I will discontinue our therapy sessions to prevent any harm to you, to myself as practitioner, or to my therapy practice. I have made these disclosures voluntarily and, while I make no representations that the information contained herein will remain accurate during the duration of our practitioner-client relationship, I will work within the terms of this disclosure as far as I am able. Client Acknowledgment and Consent to Receive Services I have read and understand the above Disclosure about the energy therapy treatment offered and have discussed with my practitioner the nature of the services to be provided. I consent to and affirm all the terms included in this Disclosure, and agree to read all material provided to me regarding my practitioner’s practice. I understand my practitioner is not a licensed physician and that energy therapy services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered, and agree to be personally responsible for all fees charged in connection with the services provided to me.

I read the Client Acknowledgment and Consent to Receive Services.

Please sign to acknowledge you have read and agreed with the Code of Ethics and Client Acknowledgement and Consent to Receive Services (Parent or Guardian Signature required for clients under 18 years of age)(Required)

Are you pregnant?

Yes

Are there any medical conditions I should be aware of?

What is your previous experience with energy healing therapy? Please share.

Do you meditate? Please share.

Do you have specific physical or emotional issues you would like to work on during your energy healing therapy session?

Do you have a specific energy healing therapy technique you would like to experience?

Emotion Code

Body Code

Pranic Healing

Crystal Healing

Animal Healing

What is your desired outcome for this session?

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Phone

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