Healing Intake

Debra Jones Healing Centre

INTAKE FORM
Please provide personal details for the client being seen.

This form remains strictly confidential.
Client Name*

First NameLast Name
If you are a caretaker filling out this form for the client - add your name here

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Phone Number*
Home Phone Number
if different from above
Client's Email*
example@example.com
Caretaker's Email
example@example.com
I'd like to receive wellness emails

Yes pleaseNo thanks
I can help you best when I consult your Astrology and Human Design charts. Please provide your birth details:
Client's Date of Birth*

DayMonthYear
City/Township of birth*
Province/State of birth*
Country of birth*
Time of birth (if unknown use 12:00 and check Time unknown)*

:HourMinutesAM/PM Option
Best guessExactTime unknown
Client's Occupation*
Reason(s) for booking a healing session*
Please describe in detail
What outcome are you hoping for?*
What other details should I know?
How did you find me? (Google, Facebook, Instagram, LinkedIn, other)
Did someone refer you?

YesNo
Who can I thank?

Emergency Contact Information
Emergency Contact Name*

First NameLast NameRelationship to you
Emergency Contact Phone Number*
Primary Care Doctor*
Primary Care Doctor Phone #
Health History
Current Health Concerns*
Mental Health Concerns
Injuries
Known Allergies
Right Handed or Left Handed

RightLeft

You're almost done ...

Thank you for putting your trust in me. I’m dedicated to providing excellent care and attention to you and your well-being.

Many people feel better from a single visit. However, the MOST benefit will come from a series of sessions as they build upon each other, strengthening your healing for SUSTAINABLE health in body, mind, and spirit.

CONFIDENTIALITY

This is a completely safe space. I value your privacy and take confidentiality very seriously. Nothing is shared beyond these walls. I will never compromise on that because I value it myself. I schedule clients so that no two people overlap. You won't run into anyone when you're here because I leave adequate time before and after each booking. This gives me time to cleanse the energy of the room before your arrival.

YOUR APPOINTMENT

Please arrive a few minutes prior to each appointment - I’ll be ready for you. I take time to prepare for your arrival and will call (out of concern for you) if you haven’t shown up. In consideration of others who need appointments, please give at least 24 hours’ notice if you must cancel. If no notice is given, the full session fee may be added to your next visit. Most sessions run about an hour, if you must leave right on time please let me know before we begin.

HOW TO BOOK, CANCEL OR RESCHEDULE

You can book, cancel or reschedule appointments online using a link in your appointment reminder, or at www.debrajones.ca

HOW TO PAY

We accept cash, cheque, or e-trans prior to info@debrajones.ca
(HST is charged on all services)

YOUR AGREEMENT

The undersigned acknowledges the following:
1. Treatments are for stress release and relaxation.
2. Energy Healing practitioners do not diagnose conditions, nor do they prescribe substances, perform medical treatment, nor interfere with the treatment of a licenced medical professional.
3. It is recommended that I see a physician or other health care professional for any physical or psychological ailment I may have.
4. The body has an ability to heal itself, and long-term imbalances may require multiple treatments to bring it back into balance.
I, {name}, acknowledge that I have reviewed and understand the policy above. I will inform the therapist of any condition that may arise during my course of treatment which has not been covered above.

I acknowledge that treatments may possibly contribute to minor discomfort (emotional release, cold symptoms, tiredness) and I release the therapist from any results that might be uncomfortable for me.
Signature*

Clear
touch screen or type
Date (select 'set')*
Should be Empty:

Debra Jones Healing Centre