Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Are you currently under the care of a Physician? If so, please provide physician's name. * How did you hear about us? * Have you ever had an energy healing session before? * Do you have an area of concern? Please describe in detail. * I understand that energy healing is used for stress reduction and relaxation. I understand that energy healing practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment of a licensed medical professional. I understand that energy healing does not take the place of medical care. It is recommended that I see a licensed medical professional for any physical or psychological problem I may have. I understand that energy healing can complement any medical or psychological care I may receive. I also understand that the body has the ability to heal itself, and to do so, complete relaxation is often 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 affirm that I have stated all my known medical conditions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I understand my identity and information about me will be held in the strictest confidence, except when released by me in writing or as required by law. I acknowledge that I have read and understand this form. Typing my name and the date and checking "I agree" below acknowledges my understanding of the above. * I agree I disagree Cancellation Policy: Thank you for purchasing a session/ multiple sessions. When booking a service, if you should need to cancel or reschedule, please inform Purple Healing, LLC within a minimum of 48 hours by your scheduled appointment. This will allow Purple Healing, LLC to find a replacement client in time. However, if you cancel after the required minimum 48 hours or fail to show, you will be charged the full service fee which cannot be used for a future session. Please understand when cancelling late or not showing up, this does not leave Purple Healing, LLC enough time to inform clients that are on a waitlist of a potential available time slot. This is not to scold you but to be respectful of Purple Healing, LLC time and your time. Life can be hectic and emergencies may arise but its important that we all respect each other’s time. Thank you for your understanding. * I agree I disagree Signature * Date * MM DD YYYY Thank you!