Name: _____________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________________

Sex:  M    F  (circle)

Date of Birth: _________________________________ Birth Place: ____________________________________

Occupation: __________________________________________________________________________________

Daytime Ph#: _______________________________(and best time to reach you): __________________________

Evening Ph#: _____________________________________________________

e-mail address: ___________________________________________________

The Distance Healing is being requested for: ___________________________Relationship: ___________________

If person is other than yourself, please complete another form. Also, please be sure to get that person’s permission to have Distance Healing done on him or her. I will not perform Distance Healing for anyone other than yourself, unless specific permission by that person has been granted.
 

List any current health problems: _________________________________________________________________

_____________________________________________________________________________________________

List health problem you are requesting Distance Healing for, be specific please:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you currently being treated for these health problems by a physician? __________________________________

_____________________________________________________________________________________________
 

List any medications you are currently taking: _______________________________________________________

_____________________________________________________________________________________________
 

Do you follow or observe any religious or meditative practices?  If so, please describe: _______________________

_____________________________________________________________________________________________
 

RELEASE STATEMENT:    I hereby authorize Energy Healing Art/D.Lewis to perform Distance Healing on me for the purposes outlined in this intake form and for future purposes that I may request.  I understand that the success of my session depends greatly on my own ability and desire to affect change in myself.  I understand that because the results of my sessions depend greatly upon my own serious participation that Energy Healing Art/D.Lewis cannot offer any guarantee of the success of my treatment.  I am aware, however, that Energy Healing Art/D.Lewis will do everything in her power to ensure the success of the Distance Healing for which I am requesting.

I also understand that although I have sought medical treatment and advice and any associated necessary treatment, I have chosen alternative healing at this time. Energy Healing Art/D.Lewis does not claim to cure diseases or replace any medical care. If you have a medical condition requiring a physician’s care, please seek professional medical care and follow the advice of your physician.

I hereby release Energy Healing Art/D.Lewis of any and all claims, litigation, arbitration, or any other legal complaints or remedies – and have agreed by signature below to enter into this Distance Healing session by my own free will.
 
 

Print Name: __________________________Signed: __________________________ Dated: __________________