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.
Current overall health condition:
Health history (list medical conditions/diagnoses, with dates/years): Hospitalizations/surgeries/accidents/injuries (date/year/complications?): Mental/emotional traumas (condition/date/year): 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.
I give my consent to receive Healing Touch from Jean S. Pruett, HTCP/I Submit