Information Form

Healing Connections Confidential Client Information

Please complete and email to Hillary at Healing Connections (hills.g@gmail.com) or print and bring to your appointment.

Remote Healing Clients please attach a recent photograph.

Date_____________

Name:_____________________________________________   Birth date: __________

Address________________________________________________________________

Phone: _________________________   Email__________________________________

☐ Married    ☐ Single   ☐ Divorced  ☐ Committed Relationship

Children?  YES ☐   NO ☐

Occupation_____________________________________________________________

Referred by: ☐ Medical Professional ☐ Friend ☐ Yellow pages ☐ Web Site

Please describe the reason for this session. Include history, symptoms, feelings, diagnosis, other treatment, medications, and what your goals are for this work.

 

Have you ever experienced energy work before? YES ☐   NO ☐

Have you been diagnosed with and/or treated for any of the following within the past 2 years?  ☐ heart disease     ☐ hypertension       ☐ allergies       ☐ anxiety              ☐autoimmune disease     ☐ fibromyalgia       ☐ chronic fatigue   ☐ depression  ☐Lyme disease   ☐ cancer     ☐ other__________________

Are you currently under the care of a medical professional or psychotherapist?         YES ☐   NO ☐

I understand that I am responsible for my health and healing and that healing science is not a substitute for traditional psychological or medical care. I understand that this work does not diagnose illness and I may be referred to other health care professionals should the need arise.  I understand that this work may enhance traditional medical care, without interfering with its efficacy.

______________________________________________                      _____________

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