Energy Healing Form

Email *

Full Name at Birth *

Current Full Name (if there are changes)

Phone Number (with area code) *

Date of Birth (dd/mm/yyyy) *

Gender *

• Male
• Female
• Does not with to disclose

Purpose of this physical healing session, Please state your desired outcome to achieve by end of the session *

Describe the ailment in detail and the treatment undertaken so far. Please provide details as to how long you have been having these specific conditions. What medical interventions you had in the past? * *

Are you currently taking any medications, please list if any?

How do you currently treat the ailment, when you get the physical pain /or emotional triggers?

A healing session does not replace any medical support or visit to Doctor but can be seen as complementary therapy to assist healing on different levels. Do you understand and agree with this ? *

• Yes
• No

Please confirm the information provided to us is true to the best of your knowledge. ( By acknowledging below, you hereby also release the healer from any liability as result of the services rendered). *

• Yes & Agreed

Submit