Confidential Client Form

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

High Blood PressureLow Blood PressurePregnantPain in Back, Hips, LegsPain in Neck, Shoulders, ArmsArthritisHead InjuriesHeadachesSkin RashDisgestive ProblemsFatigueSleep Disorders/InsomniaStress/AnxietyDiabetesDepression/SadnessCancer/TumorsOld emotional traumas or woundsSelf-limiting BeliefsHyper-sensitivitiesScarcity/poverty consciousness/not enough

ASSIGNMENTS- FULL FEE OF THE SESSION IS DUE IF 36 HOUR NOTICE IS NOT PROVIDED TO RESCHEDULE DUE TO THE ASSIGNMENTS BEING INCOMPLETE. I agree to complete assignments within the timeframe suggested to further healing and manifestation of my goals and intentions. The assignments may include: tithing, acts of service, meditation, journaling, going for a walk, being in nature, etc. I understand the assignments are essential and I accept full responsibility for stepping outside of my comfort zone as needed to complete the assignments. If the assignment isn't done at least 36 hours prior to our call, we will need to cancel or reschedule the call. 36 hours notice in advance of our appointment will be required. I understand if I do not reschedule or cancel the appointment 36 hours in advance the session will be forfeited (non-refundable and non-transferrable).I have read and agree.

Disclosure in Compliance with New California State Law Bill Number SB 577: Act to add to Sections 2053.5 & 2053.6 of the Business and Professions Code, relating to health. “I understand that the Pranic Healing Practitioner from whom I seek services is not a licensed physician or surgeon and that Pranic Healing treatments are not licensed by the state but are complementary to healing arts services licensed by the state. I understand that Pranic Healing is a highly developed system of energy based healing techniques that utilizes “Prana” to balance, harmonize and transform, the body’s energy processes by cleansing, energizing and balancing the body’s bio-electromagnetic field, or aura.”I have read and agree.

It is my choice to receive Pranic Healing. I understand these modalities are not meant to replace conventional medicine. I realize the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. This also includes relief of phobias, addictions, or emotional trauma. I understand the practitioner does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. If symptoms persist or become severe, a medical professional is to be consulted. I hereby release the person or persons providing these services from any liability of the services received. I certify that the facts given herein are correct and up-to-date and will notify the practitioner of any changes in my health status.I have read and agree.

24 HOUR CANCELLATION POLICY- FULL FEE OF THE SESSION IS DUE IF CANCELLING SOONER THAN 24 HOURS FROM SCHEDULED APPOINTMENT.I have read and agree.

Thank you for taking the time to complete the client data form.

Thank you for your business!

Please complete this CONFIDENTIAL QUESTIONNAIRE before your first session.
Thank you!