Confidential Client Form

First Name

Last Name

Phone *

Email *

Address

City

State

Postal code

Country

Are you Coachable? *

Please prioritize the areas you think we need to focus on for your session(s): *

Please list any other diagnosis or diseases not listed from above:

Do you have a history of psychological disorders? If so, please list:

Do you take recreational drugs? If so, what kinds and how often?

Do you drink? If so, how often?

Please list any past or upcoming surgeries that you have had (and approximate dates):

Please list any medications, vitamins or herbs that you are taking:

Goal Examples: I love my life. My body is healthy & full of vitality. I am open to love. I am super prosperous. I have clarity and focus. It's easy for me to hear divine intuition. (I can also help you refine your goals in your session.)

Please write each of your top 1-3 goals in a POSITIVE, PRESENT TENSE sentence below.

Homework Assignments: ASSIGNMENTS DUE 36 HOUR NOTICE PRIOR TO YOUR NEXT SESSION. I agree to complete assignments within the timeframe suggested to further healing and manifestation of my goals and intentions. The assignments may include: tithing, acts of service, meditation, journaling, going for a walk, being in nature, etc. I understand the assignments are essential and I accept full responsibility for stepping outside of my comfort zone as needed to complete the assignments. If the assignment isn't done at least 36 hours prior to our call, you will need to cancel or reschedule the call with at least 36 hours notice in advance of our appointment (or you will be charged). I understand if I do not reschedule or cancel the appointment 36 hours in advance the session will be forfeited (non-refundable and non-transferrable).

Homework Assignments

Yes, bring it on!

I don't usually follow through on my commitments.

Disclosure #1 in Compliance with New California State Law Bill Number SB 577: Act to add to Sections 2053.5 & 2053.6 of the Business and Professions Code, relating to health. “I understand that the Pranic Healing Practitioner from whom I seek services is not a licensed physician or surgeon and that Pranic Healing treatments are not licensed by the state but are complementary to healing arts services licensed by the state. I understand that Pranic Healing is a highly developed system of energy based healing techniques that utilizes “Prana” to balance, harmonize and transform, the body’s energy processes by cleansing, energizing and balancing the body’s bio-electromagnetic field, or aura.

Disclosure Agreement #1 *

I have read and agree.

Disclosure Agreement #2: It is my choice to receive Pranic Healing. I understand these modalities are not meant to replace conventional medicine. I realize the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. This also includes relief of phobias, addictions, or emotional trauma. I understand the practitioner does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. If symptoms persist or become severe, a medical professional is to be consulted. I hereby release the person or persons providing these services from any liability of the services received. I certify that the facts given herein are correct and up-to-date and will notify the practitioner of any changes in my health status.

Disclosure Agreement #2: *

I have read and agree.

Disclosure Agreement #3 Your session will remain private and confidential, unless you have given permission to share it. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Highly Perceptive People Academy, Balanced You™ and all its employees from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with our session(s).

Disclosure Agreement #3 *

I have read and agree.

Is there anything else you want me to know about you?

Who were you referred by? How did you first hear about me?

Will you please bring to your session(s) the following: *

Water

Pen & Paper

Your Goals

By typing my name below, it will be my signature to comply that I have read and agree with all of the disclosures, and filled out the form to the best of my ability. *

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