New Client Information Form

All new clients are required to complete our  Client Information Form before any appointments/sessions/bookings can be confirmed. 

The form below is your opportunity to share your goals for your session(s) as well as any concerns you may have. It also provides necessary information for my records. You must complete and submit the form below prior to your first session with me.

No form = no session. 

This Intake and Consent Form has been given to you to provide valuable information in assisting your healing.  While sharing most information in this Form is voluntary, you must fill out the contact information immediately below, as well as sign and initial the consent at the end of this Form, for us to work with you. In addition to personal information, you are asked to disclose current and past medical history protected by the Health Insurance Portability and Accountability Act.  As such, you have certain privacy rights in this information and, in compliance with the law, our HIPAA policy is attached to this form

 

All information we obtain about you, whether written or shared verbally during session, and whether from you directly or another source, will be held in the utmost confidentiality.  We will never share your information, medical or otherwise, without your express written consent and direction, unless otherwise required by law.  While providing personal and medical information about you is entirely voluntary, without this information you may impair the progress of your sessions and potentially create risks to your health.  

 

If you have any questions about how to complete this form, how we use your information, or what your rights are regarding your information, please ask your healer immediately before signing below. If you have any questions about the form, please send your message to innocencesmith@innocencesmith.com. Thank you!

Have you had any prior experience with energy Healing work {Crystal healing, Reiki, Hypnosis, Breathwork, etc...}? 

PERSONAL BACKGROUND INFORMATION

MEDICAL CONDITIONS (CHECK ALL THAT APPLY):
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I feel the following emotions frequently: I cannot feel the following emotions often/well: What is your most volatile or vulnerable emotion? 

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Click Here to Review a Copy of Our Terms & Conditions Before Submitting Your Client Form

I understand that the energy healing sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner. 

I further understand that energy healing should not be construed as a substitute for needed medical attention. Energy healing practitioners do not diagnose, treat, or prescribe for medical conditions. Energy healing brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting the more subtle energies described in other cultures with terms such as chakras, meridians, and etheric fields. 

I understand that By electronically signing and submitting this form, I agree to share this information with Innocence Smith.