This is a one-time form to be filled out prior to your initial session. Your information is kept private and confidential.










Please mark any of the following that may apply to you:

Pregnant or planning to beCancer or terminal illnessObesityEpilepsyHeart condition/pacemakerAllergies to nuts or seedsAllergies to certain plantsOther


Treatment Consent: The treatments provided are not intended to replace the advice or care of a licensed physician. Treatments with my practitioner are not intended to diagnose, treat, or cure disease, but to support the body’s natural ability to heal itself. By signing this form, I understand that there can be a detox effect from energy/body work and if it lasts greater than 4-5 days, I should contact my practitioner.

I have filled out this form to the best of my knowledge.




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