New Client Intake & Consent form
This is the example of a new client intake and consent form. You can fill this out before or during our first session. During our first session, we can review the forms and go over any questions that either one of us might have. The first session is approximately 1 hour and 25 minutes. This should allow enough time to fill out and discuss the forms, get acquainted with one another & time for the healing session.
CLIENT INTAKE FORM
(CONFIDENTIAL-FOR PRACTITIONER’S USE ONLY)
Name _________________________________________email ___________________________________________Date_______________
Address ____________________________________________________________Date of Birth_______________________
City _______________________________________________Postal Code ______________Height ________Weight _____________
Phone Home____________________________Work____________________________Occupation________________________________
Emergency Contact (name & phone)________________________________________________________________
Relationship Status________________________# Children ______________Ages ________________
How did you find me?_________________________________________ Referred by?___________________________________________
Physician (name & phone)______________________________________________________________________________________________
Therapist (name & phone)______________________________________________________________________________________________
Reason for Visit (add details on back if necessary)
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Medications___________________________________________________________________________________________________
Supplements __________________________________________________________________________________________________________
Current Complementary Therapies____________________________________________________________________________________
Eating Habits/Diet_______________________________________________________________________________
Amount Daily Intake: Water___________Caffeine__________Alcohol__________Cigarette/Tobacco_____________
Exercise routine________________________________________________________________________________
Past or current medical conditions or diagnosis. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any injuries past or present:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please list any surgeries past or future:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Please list any traumatic, or life threatening events that occurred in your life, and when they happened:
(Ex. Separation, divorce, deaths, depressions or other significant event)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
What do you hope for and what are your expectations from this healing today and long-term:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
What is your connection with spirituality (religious background, development, current practice)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Brothers/sisters _____________________________________Rank in family____________________________________________________
Relationship with mother_______________________________________________________________________________________________
As a child_______________________________________________________________________________________________________________
Present_________________________________________________________________________________________________________________
Relationship with Father________________________________________________________________________________________________
As a child_______________________________________________________________________________________________________________
General (further details on reason for visit or anything else you want to share or want me to know)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Consent for Treatment Form
Consent Form for Treatment
Welcome to my practice. This document contains important information on my work approach and my
policies. Please read it carefully and make note of any questions you may want to discuss with me and then
sign it to indicate that you are in agreement with the contents. I am very happy that we will be working
together.
As a healing facilitator, I do not medically diagnose or prescribe treatment. My approach is holistic, focusing
on you as a complex, dynamic, unique being – body, mind, and spirit – and I serve as a facilitator in your
process of healing.
My approach involves working with the body and the energy field, as well as the consciousness associated
with the causes of imbalance. I work directly with the energy field and through/by the body to bring
awareness to the underlying, often unconscious, reasons that create creating protective blocks in order to feel
safe, but that prevents you from fully enjoying life and being in the full essence of who you are. Our goal is to
free up these blocks so that you can fully be yourself and be well. The work is collaborative and requires a
commitment on your part to be curious and to study yourself as we work together. We may explore areas that influence your state of wellbeing, such as your health history, life stressors, your belief systems and attitudes, your family and childhood history, diet, exercise, and relationships.
The hands-on energy healing techniques balance, clear, and charge your energy field and system, remove
energetic blocks that lead to disease or dis-ease, and enhance your body’s natural healing potential.
At times I will touch your body, by lightly placing my hands on top of your body and at other times I may work with your energy field off your body. I may also use sound to free up blocks. If at any time during the session you are uncomfortable, it is your responsibility to inform me.
Self-care is an extremely important part of your healing process.
Please be aware that the work may bring up strong emotions and powerful feelings. Due to the nature of this
work, please do not come to the session under the influence of drugs or alcohol and I recommend that you
refrain from using alcoholic beverages for 24 hours following your session. It is your responsibily to inform me of any drugs that you are taking.
Confidentiality
Your sharing is always kept confidential. I do, however, discuss clients (without identifying them) with my
professional supervisor or professional peers for the purpose of my continuing professional development.
According to the law, confidentiality will not be respected in the following cases:
• If you present a danger to yourself;
• If you present an imminent danger to another person;
• If there is the reason to believe that child or elder abuse or neglect is present.
Telephone and email
I try to return phone calls and emails as soon as I can.
Telephone and email are not the best way to deal with issues or feelings that are best brought up in the
container of the sessions. It is better to schedule another session or journal what is happening until our next session.
Please be aware that email is not confidential and may be intercepted while traveling on the internet and I
cannot be responsible for any information that might become public in email that you send me or an email
response that you get from me.
Telephone consultations exceeding 10 minutes will be billed as half of a session and consultations exceeding
30 minutes will be billed as a full session.
Cancellation of an appointment
I require that you advise me within a minimum of 24 hours (preferably 48 hours) in advance of a change or
cancellation for an appointment; otherwise, the full payment of the session will be due and must be paid prior
to continuing treatments. Exceptions might be considered for illness or inclement weather that would make
travel dangerous or impossible. Remember that it is always possible in this case to work by phone or Skype.
Initial___________
Lateness
If you are late for an appointment, we will use the time that is remaining in your scheduled time slot; full
payment will still be due. Please call to tell me that you are running late. If I do not hear from you I will assume you are not coming. You will be billed for the full appointment time.
The duration of the first session is approximately one 55 min. and the subsequent sessions are 55 minutes. If
you feel you need more time in a session, it is possible to schedule a longer session ahead of time; the fee will
be adjusted accordingly.
Initial____________
Payment
Payment is due at the end of each session and can be made by check or cash at the office or ahead of time
from my website by email transfer from your bank account using Paypal. My Paypal acct is Tania@DivineMatrixHealings.com. Checks returned by the bank-There is a $40 charge for processing checks returned by the bank.
Initial__________
Questions and concerns
I am most happy to answer questions regarding my services, and I also encourage you to express any concerns
that you may have.
Consent and limits of practice
I have read and understood the above information provided by Tania Buchanan Boyd, I further understand that her
services are not to be interpreted as psychotherapy, medical examination or a diagnosis. This is not a substitute for
medical treatment and that nothing said or done during the course of the session given should be interpreted
as such.
Initial _________
Any questions have been answered to my satisfaction.
I confirm that I am presenting myself in my own name, in good faith and for no other reason than obtaining a natural and holistic treatment.
Print:________________________________________________________ Date:___________________
Signature:____________________________________________________ Date:__________________
