Name

First Name

Last Name

Date of Birth

YYYY

Best Phone

(###)

###

####

Email Address

May I add you to my email list?

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone #

(###)

###

####

Medical Conditions I should be aware of:

Are you currently receiving psychological care?

Do you ever feel anxious when doing relaxing activities, i.e. yoga, meditation, massage?

Yes

Pregnant?

Please let me know if you are expecting.

Yes

Pacemaker / Port?

Do you have a pacemaker or port?

Pacemaker

Port

Please list any sensitivities, allergies or aversions to essential oils or other smells.

Additional Information (Optional): Specific areas of concern? Do you have an intention to share? How may I best support you?

Referral information:

Who may I thank for your referral? Or, how did you find me/my services?

Disclaimer: Energy medicine modalities (sound healing/therapy, Reiki, gemstones/crystals, essential oils, etc.) are natural methods of energy balancing, but are not meant as a substitute for medical and/or psychological diagnosis and treatment. Energy healing practitioners do not diagnose conditions, nor do they perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. All therapies and treatments offered are meant to complement prescribed medical/psychological treatments.

I understand Amy Green is not a licensed medical/mental health professional.