Biofield Tuning Client Intake Form

Name

Address

City / State / Zip

Birthday

Referred By

Desired Session Location(required)

In Person Remote (Phone or Zoom)

Contact Information

Home Phone

Cell Phone

Email

Emergency Contact: Name

Phone

Medical History

Other

Please mark any of the following contraindications that may apply to you:(required)

Surgeries (Please include location and approximate dates)

Medications

Current Nutritional and Herbal Supplements

All answers on this form are confidential. However; if substance-use appears to be life threatening, I am required by law to report it: Alcohol / Caffeine / Tobacco Use (Please include amount used and frequency)

Recreational Drug Use (Please include amount used and frequency)

Describe any major accidents or traumatic events (Please include approximate dates)

Background Information

What gives you joy?

How do you deal with stress?

How do you relax?

How do you take care of your body?

What do you hope to gain from your Biofield Tuning sessions?

Describe problems you wish to address. Include how long you have had them, any medical diagnosis for them, treatments you have tried, and their effectiveness:

PLEASE READ CAREFULLY:

I understand that the Biofield Tuning sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner.
I further understand that Biofield Tuning should not be construed as a substitute for needed medical attention. BIOFIELD TUNING PRACTITIONERS do not diagnose, treat, or prescribe for medical conditions. Biofield Tuning brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting the more subtle energies described in other cultures with terms such as chakras, meridians, and etheric fields.

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