Lightworker Studio Pre-Session Energy Healing Intake Form

Signature (Parent if Under 18):

Client Age

Email

Emergency Contact

Physician's Name:

When was your last session?

Do you have a particular area of concern?

Do you take any prescribed drugs/medications? If yes, please specify:

Do you have history of serious illness or diseases? If yes, please specify:

Do you have a history of psychological disorder? If yes, please specify:

Do you have a history of serious physical injury? If yes, please specify:

Rate Your Pain/Discomfort Now (0-10): 0= No Pain ; 5 = Moderate; 10 Unbearable

Other Comments or Symptoms

Client Signature:

I understand that energy healing is not meant to replace conventional medicine but rather to complement and enhance it. I understand that energy 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. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that energy healing can compliment any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I agree to hold harmless any claims, lawsuits, demands, causes of action, liability, loss, damage and/or injury of any kind whatsoever (including without limitation of all claims for monetary loss, property damage, equitable relief, personal illness including the novel coronavirus, COVID-19 and/or personal and emotional injury) arising out of Lightworker Studio sessions. I further understand that there are numerous benefits possible through Sound and Energy Healing and intuitively guided experiences, such as diminished pain sensation, increased relaxation, relief from anxiety, healing of traumas and enhanced sense of well-being. These effects may vary depending on each individual’s response patterns. Although there are no known harmful effects from this type of intervention, I hold Lightworker Studio and Chris Gamboa harmless from any possible effects that may cause physical or emotional discomfort, illness, injuries or death and for any losses or damages thereto and agree to take full responsibility for my self-care and personal development. I am in control of my own body and I can always “stop” at any time. Name:

Signature (Parent if under 18):

No information about the client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.