Energy Healing Arts Services Intake Form
Please complete this form to the best of your ability.
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Email *
Name *
Street, City, State, Zip *
Phone Number *
Gender *
Preferred Gender Pronouns *
Date of Birth *
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Relationship Status *
Emergency Contact - First & Last Name *
Emergency Contact Street, City, State, ZIP *
Emergency Contact Best Phone Number *
Emergency Contact Email *
Discovery Information
If you are completing this form on behalf of the client, please provide answers from their perspective.

If you are completing his form on behalf of a minor, please modify the questions to fit the minor and be specific with details provided. This form must be completed by the legal guardian(s) of the minor or by the minor’s legal parent(s).

Some of these questions might seem “odd,” however, the answers help support the work we may do in our sessions.

If you are unable to type your answers below, feel free to use another document / paper to answer the questions.

1. Have you worked with an energy healing or shamanic practitioner previously? *
If Yes, please provide dates and describe the work and situation you sought support for. *
2. Have you worked with a practitioner * for this issue * previously? *
If Yes, please provide dates and describe the work and situation you sought support for. *
3. Is there any ancestral, familial or historical significance to your name? For instance, are you named after a (deceased or living) family member, famous person (dead or alive), god or goddess, mythical being, etc? *
If so, please share: *
4. What family of origin and immediate family members have passed in your lifetime? Please list the cause of each family member listed. *
5. Please list family members that passed traumatically prior to your birth and any whose story is repeated or honored frequently in your family. Also include the cause of the passing. *
6. List the number of pregnancies and dates of pregnancy. If you are male or the parenting partner at the time of conception or birth, list pregnancies you have fathered or been partner to: *
7. List first names and birth dates of live births. If the child has passed, please indicate and include date and cause of passing: *
8. Are your children named after a (deceased or living) family member, famous person (dead or alive), god or goddess, mythical being, etc? *
If Yes, please share: *
9. Have you ever seen a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
If Yes, are you currently seeing a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
10. Please list dates or periods of time when you worked with a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
11. Are you currently taking prescription medications of any kind? *
If Yes, please list each medicine and its purpose: *
12. Do you take alternative supplements to help with your emotional, physical or spiritual well-being? *
13. Please list and describe any recurring or unresolved condition, illnesses, injuries or symptoms you have experienced in the recent years.       *
14. Please list anything that may have occurred just prior to the onset of the condition *
15. Have you seen a physician or helping professional about the condition you described in the previous question. *
If yes, what type of physician or helping professional have you seen for the condition? *
16. Regarding any incident, injury, or illness that occurred just prior to the onset of the condition for which you are seeking support, please provide any additional information that may be insightful. *
17. Do you have allergies of any kind? If so, please list and explain: *
18. On a scale of 0 to 10, 10 being as much as humanly possible, provide a ranking for the level of self love you feel toward yourself today: *
19. Has this rating changed in the recent past? If so, describe: *
20. If you have you suffered from any of the following in the past or present, please share details you feel are important for me to know: *
21. Depression *
If yes, please share details you feel are important for me to know: *
22. Post Traumatic Stress Disorder *
If yes, was it diagnosed by a physician? *
23. Dissociation *
24. Anxiety *
25. Panic Attacks *
26. Chronic Stress *
If yes, please describe: *
27. Sleep Disorders *
If yes, what was the diagnosis? *
28. Going to Sleep *
29. Staying Asleep *
30. Anger Issues or Challenges *
31. Substance Issues *
32. Compulsive Behaviors *
If Yes, please specify or describe: *
33. Chronic Illness *
If Yes, please provide details and include dates: *
34. Please list dates and details of all surgeries, procedures, and events where you received anesthesia *
35. Please list dates of terminated pregnancies *
36. Please list dates of miscarriages *
37. Please list birthdates of children you have adopted and any details you think are important *
38. Do you experience negative self-talk? *
If yes, what is the theme of negative self talk? *
When does it happen? *
Describe what it sounds like *
Are there different voices? If yes, please describe and provide any other details you feel are important *
39. Do you have a sense that something is missing? *
If yes, please describe *
40. Do you experience a sense of shame? *
If Yes, please describe: *
41. Do you experience procrastination? *
If Yes, please describe: *
42. Do you experience mood swings? *
If Yes, please describe the 1) range of the mood swings, 2) what triggers them and 3) if they happen more often during certain times of day, of the week, seasons, holidays, etc: *
43. Paranormal experiences? *
Please describe, if yes. *
44. Recurrent bad luck? *
If yes, please describe: *
45. Traumatic Loss *
If yes, please describe: *
46. Do you have a spiritual foundation? *
Please describe: *
47. Does your home have geopathic stress?
Clear selection
48. Do you your family members or pets have repetitive or recurring health or emotional concerns?
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49. Is there a persistent presence of unwanted or uncomfortable energy in your home?
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50. Have there been recurrent water leakages, cold and damp areas, mold, etcetera in your home?
Clear selection
51. Do you awaken in the morning feeling fully rested and refreshed?
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52. Do you feel your immune system is weak more often than not?
Clear selection
53. Has there ever been an electrical fire in your home?
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54. Do you have a feeling that there is something wrong with your home – it doesn’t feel right – you don’t look forward to going home – you feel better away from home?
Clear selection
55. Since moving into your home, have you been diagnosed with cancer, Myalgic Encephalomyelitis (ME), multiple sclerosis, an autoimmune disorder or an illness that doesn’t respond to treatment?
Clear selection
56. Have you or any other family member become not well after moving to your new home?
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57.Previous occupants of your house / home have a history of cancer or other serious illnesses
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58. Inside or outside of your home are there signs of physical decay, unresolved clutter, piles of rubbish, cracks in glass, brick, plasterwork, recurring mechanical and electrical issues, food spoils quickly, certain types of paper loses its quality or other similar issues?
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59. If you have other health issues I haven't asked about, please list kind and date: *
60. What would you like to have differently in your life? *
61.  What else would you like to share with me, even if it sounds weird? *
62. As you completed this intake, is there anything I failed to ask that you believe could be important to the success of our work together? *
63. What do you think is going on? Please describe any thoughts you have about what you are experiencing. *
I have answered the questions and provided the information with complete accuracy and transparency. I understand that this information is important to understanding the client, their situation and to providing the best care possible.

Client or Guardian Signature (your signature is your typed legal name) *
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