Your Name
*
First Name
Last Name
Mobile Number
*
Country
(###)
###
####
Email Address
*
What is your home address?
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Whom may I thank for referring you?
Program & Service Name
*
Bio-Energetic Aromatherapy
Bio-Energy Vibrational Tuning
Access Bars
Access Energetic Facelift
Access Bars Class
Coaching/Consultation
Date of Your Appointment
*
MM
DD
YYYY
Time of Your Appointment
*
Hour
Minute
Second
AM
PM
Depression
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Mood Swings
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Anger
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Sleep Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Anxiety
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Alcohol/Drug Use
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Panic Attacks
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Memory Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Eating Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Hormonal Imbalance
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Allergies
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Work-Related Stress
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Home-Related Stress
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Other
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Other
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Other
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Are you currently taking any kind of medications?
*
No
Yes
If Yes, please list:
Have you had any illnesses, injuries, trauma or surgeries that may be affecting your health right now?
No
Yes
If Yes, please explain:
Are you currently experiencing any symptoms; such as pain, tension, anxiety, etc?
No
Yes
If yes, please explain:
How does this affect your daily activities; such as sleep, exercise, decision-making, relationships?
No
Yes
If yes, please explain:
What is your intention and desired outcomes for today’s session?
Is your long-term goals for your health?
Is there anything else you would like us to know?
Who should we call in case of emergency?
*
First & Last Name
First Name
Last Name
*
Emergency's Contact Phone Number
Country
(###)
###
####
Consent & Personal Responsibility
*
I give consent and permission to JoyFULL Being to conduct a session to balance my energy system, which may include light touch at various points on my body. I understand that this may consist of Aromatherapy, Bodywork, Bio-Energy, Emotion Code and other energy therapies. An assessment may be conducted to determine the general health of my subtle energy system, and share this information with me.
I understand that these sessions with my practitioner are to balance and clearing my body’s subtle energy system to support my body’s natural healing ability and are NOT intended to replace appropriate medical treatment or mental health counseling. I understand that these sessions do not constitute a physician/patient relationship and that a practitioner of JoyFULL Being does not diagnose or treat any medical conditions. Information given is not intended to replace medical advice. If I have questions or concerns about my health, I will consult my physician. I take full responsibility for my own health and well being.
I have stated all of my known conditions and will keep the practitioner updated on my health in future sessions, especially regarding, but not limited to, pregnancy, serious injury, illness or psychological conditions.
No guarantees or claims as to the results of treatment are expressed or implied by a practitioner. I understand that no adverse side effects have been documents from energy therapies, but this does NOT mean that I will not experience adverse side effects.
Once the goal of my treatment identified during the treatment process, I promise to participate in my personal goal setting actively. I agree to raise questions about anything I do not understand. I know that I am always in control and is empowered to stop a session at any time. Strict confidentiality is a guarantee regarding any of my sessions.
