New Client Form

Please complete the following form before your first energy healing therapy session. The information provided will remain strictly confidential and will help us understand your needs and ensure a safe and effective therapy experience. If you have any questions regarding this form, please feel free to ask.

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Medical History

Please provide details regarding any significant medical conditions, past surgeries, or ongoing treatments

Medications/Supplements

Please list any prescription or over-the-counter medications and supplements you are currently taking

Allergies

Do you have any known allergies or sensitivities? If yes, please specify

Presenting Issues

Please describe the main reasons for seeking energy healing therapy and any specific issues or concerns you would like to address during the sessions

Previous Therapies

Have you received energy healing therapy or any other form of complementary or alternative therapy before? If yes, please provide details

Psychological Health

Please indicate if you have received or are currently receiving treatment for any Psychological health conditions. If yes, please provide details

Physical Health

Please indicate if you have any physical health conditions or limitations that may impact your participation in energy healing therapy

Additional Information

Please share any additional information you believe is important for us to know about your overall health, well-being, or specific requirements

Signature

I hereby acknowledge that the information provided above is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the therapist of any changes to this information in subsequent sessions. I agree to hold the therapist and We Heal Therapies LTD harmless from any liability resulting from the information provided on this form. By submitting this form I also agree to We Heal Therapies LTD privacy policy, and Terms and Conditions. (Please Read T&C's)

I Agree

Date

YYYY