Energy Cleanse Intake

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I consider the use of sound, energy, 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. 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, etc. 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.

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

Please fill out this Energy Cleanse Intake form prior to your appointment . 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.

Cancellation Policy: If you need to reschedule or cancel your appointment, please notify us at least 48 hours in advance. Any sessions cancelled without 48 hour notice will forfeit session fee.

By placing your initials below, you agree to the Cancellation Policy for this session and future sessions. This is required for any and all sessions booked.

Terms & Conditions: It is my choice to receive Energy Healing and I understand that the practitioner may use gentle sound and vibration, essential oils, burning sage, and crystals during the sessions on/around me. I have completed this form to the best of my knowledge. I understand that practitioners do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for those services. By typing my name below I agree to the terms and conditions are accepted and agreed upon:
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Email Address *

Phone Number *

What is your preferred form of communication? *

Phone

Text

Have you participated in an Energy Cleanse before? If so, when? *

Describe an Energy Cleanse in your own words? What is it? What does it DO? *

What do you hope to get out of Energy Cleanse session? What are your expectations? *

What issues do you have that you would like addressed through the cleanse? (Physical, emotional, mental, spiritual) What are your areas of concern? *

What are your current spiritual practices, if any? *

Describe a place that brings you peace, even if you have never been there before. In other words, describe your "happy place." *

What other means of healing have you pursued? (medical doctors, healers, reiki, sound healing, etc.) *

Anything else you think I should know? *

Do you have any allergies or sensitivities to specific scents, scented oils, metals, etc? *

Emotional Checklist - Check any 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

Crying or tearing up easily

Heightened sensitivity to physical pain

Eating to soothe your mood, or comfort eating

Required

Informed Consent: I have read the above. My purpose to seeking an energy cleanse is for personal purposes only.

I understand that YOMEI does 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 YOMEI cannot be held liable for any problems that might arise that I think could be attributed to the Energy Cleanse session. I acknowledge that YOMEI practices for the purpose of providing mental/emotional/physical and spiritual support through multiple techniques. I attest that I understand the nature of the session and freely elect to receive the techniques. I release YOMEI from any and all claims of malpractice, non-disclosure, or lack of informed consent.

By entering your name, you agree to the Informed Consent.

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