Intake & Consent Form

Email *

Name *

First

Last

Preferred Pronouns *

she/her
he/him
they/them
other

Phone *

Preferred Contact Method *

Email
Phone
Text

Age

Please tell me who referred you so I can thank them:

Are you currently experiencing pain? *

Yes
No

Pain Scale

0-3 Occasional or mild pain
4-6 Moderate pain
7-8 Significant pain
9-10 Severe pain

Do you regularly experience anxiety? *

Yes
No

Anxiety Scale

0-3 Occasional or mild
4-6 Moderate
7-8 Significant
9-10 Severe

Do you experience fatigue? *

Yes
No

Fatigue Scale

0-3 Occasional or mild
4-6 Moderate
7-8 Significant
9-10 Severe

What are your goals for our session together? *

Are there any questions or concerns you would like to address before our session? *

Please mark any of the following that may apply to you: *

If you marked any of the above, please feel free to add more details:

Treatment Consent: The treatments provided in Biofield Tuning are not intended to replace the advice or care of a licensed physician. Treatments with my practitioner are not intended to diagnose, treat, or cure disease, but to support the body's natural ability to heal itself. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Renee Einarson & Neural Coherence Biofield Tuning from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). By agreeing to this form, I understand the above and the information provided on the Biofield Tuning Disclaimer I have received. I also understand that there can be a detox effect from energy/body work that can last from 3-5 days. I have filled out this form to the best of my knowledge.

I agree (this will be your "signature"): *

Yes
No

Get In Touch

Call

Message