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Coaching, Reiki, EFT, Flower Essences, Weight Loss

Client Background Information Form

Please completely fill out the form below and submit prior to a session.

Todays Date:
Name:
Sex:
Phone:
Full Mailing Address:
Email:
Birth Date:
Marital Status:
Employment:

Have you recieved the service(s) you are requesting before?

Are you under care of any health professional?

What are your reasons for wanting my services at this time?(if more than one, type them in "other" box provided)
to deal with negative or painful thoughts of emotions
For greaterspiritualawareness
for help in my relationships with others
for physical healing
for weight loss
For greater clarity about my life work, goals and direction
to bring about a more positive attitude toward life
to improve my self image and feelings about myself
for help in an immediate issue
to enhance my creativity and self-expression
for long term inner growth and change
to cope with dress and the demands of life
other

Please comment on above areas:

Which services are you requesting for this session?(if more than one, type them in "other" box provided)
intuition and readings
Reiki
Flower Essence Therapy
EFT
Coaching and Personal Lifestyle Consutling
Weight Loss or Vitality Coaching
Kinesiology
Other

Breifly describe your current state of physical health:

Emotional outlook (feelings about self and others, ongoing issues, areas of conflict...)

Mental outlook (attitude in and towards life)

Spiritual outlook:

Employment outlook:

Relationships with others and love:

Family background:

Hobbies and Interests:

Other therapies or medications you are using now:

Please rate the following on a scale of one to ten (will help me in knowing how to facilitate discussion)

Self Esteem:
1 2 3 4 5 6 7 8 9 10

Responsibility:
1 2 3 4 5 6 7 8 9 10

Openess to change:
1 2 3 4 5 6 7 8 9 10

Belief in Higher Power:
Yes No





Disclaimer: Coaching, Reiki, Intuition/Tarot and Consulting are not counseling or therapy and not intended to act as such or replace qualified medical, psychological or other care. I make no claims to treat, cure or diagnose any condition and any information provided, or goals created around weight loss, health, diet or exercise is for taking into consideration on the advice of a qualified professional. If you think medical attention, nutritional attention or psychotherapy or counseling is something you are looking for, please seek the services of a professional. It does not mean that you cannot use my services, but that can be used in conjunction.