Quantum-Touch^® energy healing                                Session Intake Form

Name:________________________________________          Phone: _______________________

Address:______________________________________________________________________________

When were you last seen by a healthcare practitioner (medical or otherwise)? _____________

How did you hear about Quantum-Touch?  _____________________________________________

What are the most important concerns I can help you with today, and how severe are they?
Please list your concerns and then circle how you rate their intensity, using a scale of 0 to 10
0 = barely noticeable and 10 = very severe

 

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2)    _________________________________________________________________________________           0           1           2           3           4           5           6          7         8          9          10

3) _________________________________________________________________________________           0           1           2           3           4           5           6          7         8          9          10

4) _________________________________________________________________________________           0           1           2           3           4           5           6          7         8          9          10

 Anything you would like to add?

Client Signature:______________________________________  Date:________________