Sample Client Intake Form – You may brand and modify as you see fit.

Please consult with your

lawyer to confirm the items in this form apply to your business. I am not a lawyer, nor do I give
out legal advice.

CLIENT INTAKE FORM

We appreciate you taking the time to review this information, complete the enclosed form and
supply us with the items requested below.

Please fill out this New Client Assessment form prior to your appointment and send it back at
least 5 days in advance to (email). If the form is received the day of our meeting, we may
need to spend time reviewing it, which takes time away from your healing session.

Your healing sessions will consist of a quick introduction before we start and a wrap-up
afterwards.

CANCELLATION POLICY

If you need to reschedule or cancel your appointment, please notify us at least 48 hours in
advance to avoid a cancellation fee. Any sessions cancelled within 48 hours, will incur the full
session fee.

___________________________________
By placing an “x” in the box above and entering your name, you agree to the Cancellation Policy
for this session and future sessions. This is required for any and all sessions booked.

INFORMED CONSENT FORM

The United States of America currently has no licensing policy in regard to Sound or Energy
Healing, and (your name) is not a licensed Medical Doctor or therapist. I do not deal with drugs,
nor do I issue a diagnosis or suggest cures.

My purpose is simply to provide a safe space for my client to experience healing through
natural processes. I consider the use of sound, energy, herbs, essential oils, crystals and any
other natural healing modality as a way to encourage the body to get back to optimal
functioning and everyone reacts to these methods individually. I make no claims for their
medicinal actions, nor do I cite scientific evidence. Any information offered is done so on the
basis of personal experience and traditional uses.

My clients agree to make their own choices as to what they do with the educational material
they have been offered and are solely responsible for their own decisions and actions. It is
always my recommendation to seek out the advice of a licensed health care professional
whenever they feel it is necessary in regards to their own personal health, especially with
serious conditions. Clients need to consult with their physician and get approval to attend
healing sessions if they have metal in their bodies, suffered concussions, have a pacemaker, use
an insulin pump, and the like. If in doubt, consult your physician before our time together.

Some issues such as suicidal thoughts or late-stage cancer are beyond the scope of my
expertise and I would advise you to seek outside help.

I understand that:
 An assessment will be conducted to determine the general health of my energy system
 Any suggestion made by (your name) will be to assist my body’s natural ability to
achieve a balanced state, to the extent that my body or my highest knowing will allow
 The goal of my session will be identified as part of the initial process and that I will have
input as well as give intent and permission for it.
 These sessions are not meant to replace treatment by established medical practices,
and can complement them.
 There are no guarantees as to the results of treatment
 (your name) is not a licensed physician and will neither diagnose nor prescribe any
condition nor does she make any specific claims regarding results from the sessions that
I receive. Nothing in the work (your name) does is considered the practice of medicine.

I agree to:
 Raise any questions or concerns about anything I do not understand.
 Consider any suggestions that the practitioner may raise concerning referrals to other
health care practitioners, homework, or my desired focus/introspection.
 Take full responsibility for my own health care.
 Give consent to (your name) to conduct a session to balance my energy system. I
acknowledge that this could involves touch and I can request otherwise.

WHAT TO EXPECT

In general, a typical session begins with a short assessment to discuss your concerns, thoughts
or questions. During the session you can choose to sit or lay down. While we try to make you as
comfortable as possible, if you have specific needs, please bring your own pillow or blanket, etc.
We make every effort to assure that our clients feel safe and comfortable.

We may work on your body or above your body, so please let us know if there are any areas
that you do not want work done. If you do not wish to be touched please let us know. Our work
is intuitive so we feel the energy and work where the energy is stagnant, deficient, stuck or
unbalanced. You may feel many different results such as heat or cold, shivers, nausea,
headache, relaxation, release, relief, ect. You may also feel nothing at all. Any reactions can
happen immediately or even months later. No reaction is positive or negative, it purely is. It
may mean something to you right away or it could be a mystery for a while. Both are normal.
We find that energy medicine has a cumulative effect, so when you treat yourself to regular
sessions, better health and well-being are natural outcomes. At the end, we will check in about
anything that came up for you during the session.

I have read the above statements and I understand and agree with them. My purpose to
seeking the advice of (your name) is done so for educational purposes only.

I understand that (your name) do not diagnose illness, disease, or mental disorder. Nor do they
prescribe medical treatment or pharmaceuticals. It has been made clear that my session is not a
substitute for medical examination or diagnosis and that it is recommended that I see a medical
doctor for any physical or mental ailment.

I agree that (your name) cannot be held liable for any problems that might arise that I think
could be attributed to the energy healing season. I have stated all of my known medical
conditions to (your name) and if necessary I will keep her updated on my physical, mental, and
emotional health. I acknowledge that (your name) practices for the purpose of providing
mental/emotional/physical and spiritual support multiple techniques. I attest that I understand
the nature of the session and freely elect to receive the techniques. I release (your name)
from any and all claims of malpractice, non-disclosure, or lack of informed consent.

__________________________________
By placing an “x” in the box above and entering your name, you agree to the Informed Consent.
HEALTH PROFILE

Name: Age:

Phone #: (HOME) (CELL)

Preference: Home Cell

Full mailing address:

E-mail Address: Referred by:

Date of Appointment: Day of Week: Time:

What is your current health goal/what do you hope to get out of this session?

AREAS OF CONCERN:
In this section, list your main issues and rate them by severity on a scale of 1-10, with 10 being
the most severe.

Please note that we will address as many issues as possible, but it’s often best to deal with
fewer at a time. This is why booking multiple sessions is important.

Issue Severity

What do you believe is/are the cause(s) of these issues?

What have you done thus far to help alleviate these issues?

Are you currently under the care of a physician? If so, what for?

What are your most pressing current physical and emotional health issues (acute and chronic)?

Any past accidents? Operations?

Do you have any specific spiritual practice?

Anything else you think I should know?

 Allergies
Do you have allergies? No Yes, to what?
Medication or herb No Yes, to what?
allergies?
Food allergies No Yes, to what?
Sensitive Skin? No Yes, to what?

Emotional Checklist
Put an X next to each statement that corresponds to the way you often feel.
Anxiety and feeling overwhelmed or stressed, especially anxiety felt in the body, or physical anxiety
Feeling worried or fearful
Have intrusive thoughts, have an overactive brain, or have unwanted thoughts – especially
thoughts about unpleasant memories, images or worries
Panic attacks
Unable to relax or loosen up
Stiff or tense muscles
Feeling stressed and burned-out
Obsessive thoughts or behaviors
Perfectionism or being overly controlling
Irritability
Winter blues or seasonal affective disorder
Negativity or depression
Excessive self-criticism
Craving carbs, alcohol, or drugs for relaxation and calming
Low self-esteem and poor self-confidence
PMS or menopausal mood swings
Hyperactivity
Anger or rage, agitated easily or irritated
Digestive issues
Fibromyalgia, temporomandibular joint syndrome, or other pain syndromes
Difficulty getting to sleep
Insomnia or disturbed sleep
Lack of energy
Lack of focus
Lack of drive and low motivation
Attention deficit disorder
Heightened sensitivity to emotional pain
Heightened sensitivity to physical pain
Crying or tearing up easily
Eating to soothe your mood, or comfort eating