Healing Touch Intake Form

** Please fill out all fields below. If the form is incomplete upon submission, a red outline will highlight the field(s) that need to be addressed. Please allow a few moments for the submission to process before exiting the window.

General Information

Self Care

Use scale 1-10, with 10 as an extreme issue, to rate areas of concern. Please describe any items rated 7 or above.

Relevant Health History

Current overall health condition:
Supplements Used:

Nutrition / Diet

I hereby declare that: 

 

  • I have been informed of the background and credentials of Jean S. Pruett and that she is a Healing Touch Certified Practitioner and Instructor as well as a Pastoral Psychotherapist and Licensed Professional Counselor.

 

  • I also have been informed that she is not licensed to practice medicine in this state and therefore will not make a medical diagnosis nor prescribe any medications. I have been encouraged to consult a licensed medical practitioner as needed and have agreed to take responsibility for my own health care.

  • I have been informed that Healing Touch is a gentle, complementary energy based approach not intended to replace any other medical care that I may be advised to seek by my licensed health care providers.

 

  • I understand that Healing Touch uses light touch and/or no touch to assist my body in its natural ability to achieve health and wholeness.

 

  • I have been informed that no specific claims have been or will be made regarding results from the Healing Touch sessions that I receive. Treatment goal(s) will be identified as part of the assessment, and I will have input into the goal setting process.

  • I have been informed that all client information & records are treated in a confidential manner and that no information will be released to anyone without my prior written consent except in situations governed by law.

 

  • My questions have been answered to my satisfaction regarding my Healing Touch Practitioner’s background, Healing Touch, and what I might expect from this session.

  • 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.

By signing my name in the box below, I authenticate that I have read, understand and agree to the terms of the Professional Disclosure Statement and Privacy Policy