Transformational You
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Medical Spiritual Healing
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Hijama Therapy
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Medical Intake Form
Emotional Intake Form
Emergency Contact Form
Waiver and Release of Liability Form
Parent/Guardian Waiver for Minors
Family Healing Survey Form
Home
About
Our Mission
Our Founder
Testimonials
Videos
Experience
Medical Spiritual Healing
Healing Family Dynamics
Hijama Therapy
Transformational You
Getting to the heart of the issue
Services
Connect
Forms
Medical Intake Form
Emotional Intake Form
Emergency Contact Form
Waiver and Release of Liability Form
Parent/Guardian Waiver for Minors
Family Healing Survey Form
Emotional Intake Form
Name
*
First Name
Last Name
Email
*
Date
MM
DD
YYYY
Occupation
Martial Status
Describe your living situation. (Roomates/pets/alone; supportive or stressful, etc)
What are your hobbies/interests?
Describe your current self-care practices (exercise, meditation, relaxation, body care, journaling, etc):
Goals
What changes would you like to see in yourself as a result of this session?
What are your long term goals for working together?
Describe your perceived strengths:
Describe your perceived challenges:
Spiritual Beliefs
Please list any practices/affiliations.
Is your belief a source of support to you?
What word/name(s) do use for Higher Power?
Describe prior Spiritual Emotional Healing experience.
Please select any areas of concern:
Personal Relationships
Physical Health
Mental Health
Emotional Health
Spiritual
Work
Finances
Eating/Nutrition
Addiction
Depression
Mood swings
Anger
Anxiety
Anxiety attacks
Trauma
PTSD
Memory problems
Personal Direction
Headaches
Pain
Fatigue/lethargy
Hormonal issues
Allergies
Sleeping issues
Safety
Major Life Change
Is there anything else you want me to know?
Do you have any questions about me or Transformational You?
Thank you!