Ancient Way Healing

Please be advised that we highly value your privacy, your personal information is kept private and confidential, any information provided below will never be shared without your express written consent unless your life is at serious risk of immediate danger.

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Phone Number

Please enter a valid phone number.

Home Address*

This is particularly helpful for remote/long distance healing

Q1: Please give a brief history of any significant or ongoing medical, psychological or spiritual issues that you wish to focus on in our work together.

Be as brief and clear as possible, we will have time to discuss this in greater detail during our appointment.

Q2: Do you smoke cigarettes? *

Q3: Do you, or have you ever, taken illicit drugs (including marijuana)?*

Q4: Do you drink alcohol? *

Q5: Do you have high blood pressure? *

Q6: Do you currently, or have you ever had cancer?*

Q7: Are you currently experiencing physical pain? (if your answer is yes, please provide details within your above answer to Q1)*

Q8: Are you currently experiencing emotional distress? (if your answer is yes, please provide details within your above answer to Q1)*

Q9: Are you, or could you possibly be pregnant?*

Q10: FOR IN PERSON PATIENTS ONLY Do you have any sensory sensitivities we need to know about (such as scents, bright lights, any allergies or particular sound triggers)

Please briefly detail any allergies or sensitivities in the space provided above

Q11: Do you have any pets?

Q12: Do you have cold or flu symptoms or a fever?

Have you experience Pranic Energy Healing before?

If so, please briefly outline your experience above

Are you receiving any other medical, holistic or alternative healing treatments?*

Please briefly describe these treatments above.

Do you exercise regularly?*

Do you maintain healthy and balanced nutrition?*

Do you have a regular meditation or prayer practice?*

How many hours of sleep do you get most nights?*

How would you rate your life satisfaction level?*

Do you currently taken prescribed medications? *

If so, please provide details above

What do you hope to gain from Pranic Energy Healing?

Is there anything else that you want us to know?

How did you find Ancient Way Healing

ARE YOU TOTALLY COMMITTED TO HEALING ALL OF YOUR PHYSICAL, EMOTIONAL OR SPIRITUAL AILMENTS WITH ANCIENT WAY HEALING?*

I,   First Name*   Last Name* understand that energy healing is a subtle form of therapy that is used to alleviate stress, help manage pain and increase deep relaxation. I understand that alternative therapies are intended to complement medical, psychological and physical treatments of all kinds. I understand that Ancient Way Healing cannot prescribe or perform medical treatment and that sessions are not intended to replace licensed medical professionals. I understand that Pranic Energy Healing practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional.

I understand that Ancient Way Healing and its practitioners are not responsible for my actions past, present or future. I understand that although this treatment has little to no risk of harm that John Gray and Ancient Way Healing are not responsible for any injuries or accidents that could possibly occur during treatment or within the treatment space.

(FOR DISTANCE PATIENTS): I, First Name   Last Nameunderstand that the practitioner will be remotely sending energy to me for the duration of my energy healing session(s).

First Name*   Last Name*        Date*
  Signature*

For patients under 18 years of age, the signature of a parent/guardian is required: I give consent forFirst Name   Last Name   to receive Pranic Energy Healing treatment.

Name of parent/guardian:   First Name   Last Name
Signature:   Signature

Medical History

Client History

Ancient Way Healing Waiver

© All Rights Reserved. Created for Ancient Way Healing by Josephine King, 2023.