Living Situation (Marital status/pets/alone; home as supportive or stressful? Social, family, personal support?): What change would you like to see in yourself as a result of this session? Hobbies & interests: Spiritual beliefs/practices/affiliations: Your perceived strengths: Current self-care practices (exercise, meditation, relaxation, body care, journaling, etc): Use scale 1-10, with 10 as an extreme issue, to rate areas of concern. Please describe any items rated 7 or above. Personal Relationships Physical Health: Mental Health Emotional Health Spiritual Work Finances Eating/Nutrition Addiction Depression Mood Swings Anger Anxiety Panic or Anxiety Attacks Trauma PTSD Memory problems Personal Direction Headaches Pain Fatigue/Lethargy Hormonal issues Allergies Sleeping Issues Safety Major Life Change Other
Current overall health condition:
To what do you attribute your current situation, symptom or health issue? Health history (list medical conditions/diagnoses, with dates/years): Hospitalizations/surgeries/accidents/injuries (date/year/complications?): Mental/emotional traumas (condition/date/year): Current prescription/over-the-counter medications/recreational drug use: Sleep quality/sleep aid usage/average hours of sleep per night: Caffeine/Alcohol/Tobacco/amount: Is there anything else you want me to know? Any questions about me or Healing Touch?
I hereby declare that:
I understand that sessions are usually 1-11⁄2 hours and that the fee per session is $50. These sessions are reserved especially for me; therefore, except in cases of extreme emergencies, any cancellation must occur 24 hours prior to the scheduled session or I will be expected to pay the full fee for the missed session.
Except in the case of gross negligence or malpractice, I or my representatives agree to full release and hold harmless Jean S. Pruett from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
I give permission for light touch.