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Full name
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Email (In providing your email, you also agree to receive periodic emails from us. We fully respect your privacy and will not share this information with anyone.)
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Age
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Profession
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Birthdate
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Marital Status
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How long have you been with your current partner?
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Is your father still alive?
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Yes
No
Is your mother still alive?
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Yes
No
If still living, are your parents still married?
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Married
Divorced
N/A
Do you have children. If so, please write their ages.
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If your parents divorced, how old were you when that happened (If this doesn't apply, put 0 as your answer)
Do you have siblings?
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YES
NO
If you have siblings, write out how many brothers you have. And how many sisters you have.
Where are you in relation to your birth order? In other words, are you a first, middle, or last born child?
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Have you ever had or had a serious disease? If yes, explain here:
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Have you ever been put under general anesthesia? If so, how many times? At what age/ages?
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What is the main reason you are seeking our services? (This could be any physical, mental, spiritual, or emotional pain...or anything else) Feel free to write as much as you want to tell us.
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0/1000 characters
Regarding your reason for contacting us: On a scale of 1 - 10, please state how you feel. 1 - not affected much at all, and 10 - the worst and highest pain.
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It is important that we do our work without interference from other sources. Are you currently seeing any other therapist, healer, or doctor? Please explain below.
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0/255 characters
What is your religion? OR Can you briefly describe your spiritual beliefs for us.. (500 max characters)
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0/255 characters
Are you right or left-handed?
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Right
Left
We would like you to feel comfortable during your healing session. There could be some sensitive personal issues that are discovered during a session. Are there any areas that you do not feel comfortable looking at? These could be issues from the past, the present, or even knowledge of the future.
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Disclaimer: By law, we are required to state that we are not a medical doctors, the information presented here is for education purposes only, and our advice is not meant to be replaced for medical diagnosis and/or treatment by your doctor. The information that we give represents our view of the world given our unique set of life experiences. These are truths as we see and understand the world at the time the words are given. Information in our sessions has not been evaluated by the FDA and is meant for educational purposes only. We cannot guarantee successful outcomes. Your health is your responsibility. Also, please know that confidentiality is important to us. We will not share your information with anyone outside of Higher Soul Healing, which is just Zé and I. - By stating YES, I show that I understand these terms.
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YES
NO
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