Zero Point Healers - Forms for Appointment


	ABOUT SERVICES NEWS APPOINTMENTS TESTIMONIALS CONTACT

Please print out the forms shown below and fill them out in preparation for your first appointment. Download the Adobe Acrobat PDF version (requires Acrobat Reader, available for free here). You may also print it directly from your web browser, but the page will not format properly. To insure confidentiality, please do not email the completed form. Bring it to your appointment. For questions or problems downloading/printing, email appointments@zeropointhealers.com

Download form as an Adobe Acrobat document (.pdf)

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CONSENT FOR TREATMENT

Please read the following information and sign where indicated.

As Multidimensional Energy Therapists, we do not medically diagnose or prescribe treatment. Our approach is holistic, focusing on you as a complex, dynamic, unique being in body, mind, and spirit. We serve as a facilitator in your process of healing.

We may explore areas that influence your state of well-being, such as your health history, life stressors, your belief systems and attitudes, your family and childhood history, diet, exercise, and how you are in relationship. Your sharing is always kept confidential, with the exception of discussing clients in our professional supervision and peer consultation group, where your identity will remain anonymous. The purpose of supervision is to further our professional development as healers and to serve you in the best manner possible.

The hands-on healing techniques balance, clear, and charge your energy field, remove energetic blocks that lead to disease, and enhance your body's natural healing potential. At times, we will directly touch your body and at other times we may work with your energy field off your body. You will always wear your clothing and will generally lie on a massage table while we work. If at any time during the session you are uncomfortable, it is your responsibility to inform us. Self-care is an extremely important part of your healing process.

Due to the nature of this work, we recommend you refrain from using alcoholic beverages for 24 hours following your session. We are most happy to answer any questions regarding our services, and we encourage you to express any concerns you may have. We hope you enjoy our services as much as we truly enjoy serving.

I have read and understand the above information provided by Zero Point Healers. I further understand that the services are not to be construed as medical examination, diagnosis, or a substitute for medical treatment, and that nothing said or done during the course of any session should be construed as such.

Client signature__________________________________
Date ___________

Parent/guardian signature __________________________________
Date ____________

Healer signature(s) ________________________________________
Date _____________

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Disclosure Information

Approach We believe in the inherent worth and dignity of every human being and value respect, honesty, love, and compassion above all else. Our approach in healing is individualized according to the needs of the people involved.

Beliefs We believe that the mental, emotional, physical, and spiritual aspects of an individual are interconnected and affect each other. Self-awareness, self-acceptance, self-love, and a sense of belonging and connection to family, friends, community, and nature, as well as a sense of higher purpose in life, are all ideals that we honor.

Confidentiality All client information will be kept in strict confidence, as is dictated by law, with the following exceptions: 1) You have signed a written release of information form, 2) a court of law has ordered information released, and 3) suspected or known harm to self or others.

Fees

Two Hands Healing: $100
Four Hands Healing: $150
Six Hands Healing: $200

I have read and understand the disclosure information provided by Deborah Russell and Robert Rodgers and agree to comply with the monetary responsibilities that accompany the services provided by Zero Point Healers.

Client (or Parent/guardian) signature________________________________________________

Date _____________________________

Healer(s) signature ______________________________ _____________________________

Date_______________________________

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CONFIDENTIAL CLIENT INTAKE FORM

Name_________________________________________________Date____________________________

Address_______________________________________________________________________________

D.O.B._______________________ Height_________ Weight__________

Phone: Home_______________ Work________________ Mobile__________________

Email _______________________________

Emergency Contact (name & hone)________________-_______________________________________

Occupation_________________________________ Relationship Status_________________________

# Children ______ # Pregnancies (current?)____________ # Miscarriages_____ #Abortions_____

Physician (name & phone)_________________________________________________________________

Therapist (name & phone)_________________________________________________________________

Reason for Making this appointment_________________________________________

_______________________________________________________________________

_______________________________________________________________________

Date of Onset________________________

Current/Previous Treatment (for above)______________________________________________________

Current Medications_____________________________________________________________________

Other Therapies/Supplements______________________________________________________________

Eating Habits/Diet_______________________________________________________________________

Amount Daily Intake: Water________Caffeine_________Alcohol/Drugs_________Cigarette/Tabacco____

Exercise Routine________________________________________________________________________

Please mark the following areas of diseases or symptoms as C for current, P for past, CH for chronic. ( Explain if necessary.)

Depression _______________
Epilepsy_________________
Bronchitis_______________
Eating Disorder____________
Dizziness________________
Emphysema_____________
Mood Swings______________
Insomnia________________
Pneumonia______________
Substance Abuse___________
Migraines_______________
Tuberculosis_____________
Aids/HIV________________
Arthritis_________________
Constipation_____________
Allergies_________________
Back pain________________
Diabetes________________
Cancer__________________
Carpal Tunnel_____________
Diarrehea_______________
Chronic Fatigue___________
Gout____________________
Gastritis________________
Fever___________________
Skin Disorder_____________
Hepatitis________________
Fibromyalgia_____________
ENT____________________
Hypoglycemia___________
Fungal Infections__________
Earaches________________
Jaundice________________
Herpes_________________
Headaches_______________
Liver Disorder___________
Lymes Disease____________
Jaw Pain________________
Ulcers_________________
Mononucleosis____________

Cardiovascular

Angina_________________
Heart Attack_____________
Heart Failure ____________
Hypertension_____________

Urinary

Bladder infection_________
Kidney Stones___________

Endocrine

Adrenal______________
Pituitary ____________
Hyperthyroid___________
Hypothyroid Stroke__________

Reproductive

Endometriosis_________
Sexually Transmitted Disease____________

Please check all of the following conditions that describe your birth:

___Unmedicated, natural birth      ___Anesthesia used      ___ Forceps applied
___Complications before birth       ___ Complications after birth      ___ Breech
___ C-section      ___Drugs to induce labor      ___ Drugs to slow labor
___Premature      ___ Incubated after birth       ___ Hospitalized after birth

Other _________________________________________________
(Please describe)

Briefly describe what you know about your own birth. ______________

__________________________________________________________

___________________________________________________________

Please list any injuries you have had and currently have
_______________________________________________________________________________

_______________________________________________________________________________

Please list any surgeries you had or know you will have:__________________________

_______________________________________________________________________

Please list any traumatic or life threatening events that occurred in your life and when they happened:___________________________________________________________

_______________________________________________________________________

Who are the significant people in your life?____________________________________

_______________________________________________________________________

What do you like to do for fun and enjoyment? List any hobbies.__________________

______________________________________________________________________

What do you hope for and what are your expectations from this healing today and long-term?__________________________________________________________________

_______________________________________________________________________

Is there anything else you want us to know about?____________________________

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