Energy Work Intake Form

Client

First Name

Last Name

Email

Phone

(###)

###

####

Address

Date of Birth

MM

DD

YYYY

Occupation

Have you ever had an energy session before?

If Yes, please indicate when and what

Yes

No

If yes, please describe energy work you've had before & when

Are you sensitive to perfumes or fragrances?

Yes

No

Do you have any allergies?

What is your main reason for having Energy Healing?

Are you currently under the care of a physician

(specifically for the issue you are seeking help with)

yes

no

Briefly describe your past health history

(including major life events, surgery's, trauma's)

How is your health now?

(including current medication and /or medical or alternative treatments)

What overall outcome do you hope to receive from Energy Healing?

(rephrase your main reason for coming as a positive)

I agree to and understand the waiver

View the Waiver and Disclaimer in the link below

Yes

View the Waiver and Disclaimer

Expectations For the Session

Please come to the session in comfortable clothing, you will be asked to remove your shoes and any metal objects. All of the Energy Healing performed by Jody is non–invasive. There is minimal touch and the client remains fully clothed.

During the Bio-Energy Chakra clearing, clients may be asked to stand or sit down in a special treatment chair at different stages of the session depending on the techniques used. Depending upon the nature of a person’s condition, how serious it is and how long they have it some clients may require a second course of sessions. During the Eden Energy Medicine, may be asked to stand and lie down on a massage table, to be active participants in the session.

While clients report positive outcomes in using Jody Goddard’s services, please note that it’s not possible to guarantee any specific results and it is unknown how you will respond to Energy Healing. Participation in sessions can result in a number of benefits including improved health and well-being and resolution of the specific concerns that led you to seek consultation for yourself.

The Energy Healing provided by Jody Goddard is considered gentle and non-invasive, it’s possible during or after your session(s) to experience some physical discomfort or emotional distress that can be perceived as negative. During sessions, clients may feel heat or cold, tingling sensations and also swaying or movement of the body. Occasionally, some people have experienced dizziness, nausea, or anxiousness as a side-effect from energy work. It is also possible that clients notice very little happening initially but find their illnesses have dissipated for up to 90 days following the sessions.

Cancellations

Scheduling of appointments involves the reservation of time specifically for you. Therefore, a minimum of 24-hour advance notice is required for rescheduling or canceling an appointment. The full fee may be charged for missed appointments without such notification.

Confidentiality: No information about any client will be discussed or shared with any third party without written consent. If you are a minor under the age of 18, your parent/guardian must be present with you during your session.