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Client Intake Form Date:____________
Client Name: _____________________________ Email:______________________________
Address:_____________________________________________________________________
Home Phone: ________________ Cell Phone: _________________ Birthdate: ______________
Present Symptoms: ______________________________________________________________
_____________________________________________________________________________
When did you first notice major complaints: ____________________________________________
______________________________________________________________________________
What activities aggravate the conditions: ________________________________________________
_______________________________________________________________________________
Is this condition getting worse? __Yes __No
Please Explain: ________________________________________________________
________________________________________________________________________________
What have you done to get relief: _______________________________________________________
________________________________________________________________________________
Has there been a medical diagnosis or X-rays: _Yes _No
What are your intentions or expectations for this visit? ________________________________________
_________________________________________________________________________________
Are you under the care of a physician for any condition? _Yes _No
If Yes, please explain: _______________________________________________________________
________________________________________________ Date of last physical: _________________
Please list any comments about your health & well-being: _______________________________________
__________________________________________________________________________________
Have you had any of the following? Please check all that apply
__AIDS __Emotional Trauma __Nervous Disorders
__Allergies/Hay Fever __Fainting __Physical Traumas
__Asthma __Growths/Tumors __Pregnant Now
__Auto Accident __Head Injuries __Respiratory Problems
__Back Pain __Heart Disease __Sinus Problems
__Blood Disease __Hepatitis __Stomach Problems
__Broken Bones __High Blood Pressure __Stroke
__Cancer __Kidney Disease __Thyroid Problems
__Dizziness __Liver Disease __Tuberculosis
__Epilepsy __Mental Disorders __Other: Not listed above
Notes/Explanations/Surgeries: Please give any additional details for checked items above,
including treatments for diseases or conditions, approximate dates, and surgeries etc.:
___________________________________________________________________________________
___________________________________________________________________________________
Do you have any health problems that need further clarification? __Yes __No
If yes, please explain: ___________________________________________________________________
____________________________________________________________________________________
Please list all drugs, herbs and/or health supplements that are being taken, and how frequently: ____________________________________________________________________________________
____________________________________________________________________________________
Occupation:_________________________ Signature:
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Client Responsibility Agreement
VortexHealing® and all services performed by Lisa Ferrer are very powerful healing art forms. Therefore, it is to be expected that various situations can arise from receiving the healing art forms. On the one hand, certain problems, either physical or emotional, may be alleviated. Sometimes, deep mystical experiences occur, as well as life-change realizations. On the other hand, suppressed emotions or emotional patterns may receive enough healing energy to be pushed to surface, so they can be released or resolved, and this process may also create various physical symptoms. Also, release of physical tension in one area of the body may bring to the surface tension that has been stuck in other areas of the body, which can manifest as various body symptoms. When there is deep tension in the body, pain may occur as that tension releases and the body rearranges itself. In homeopathy, it is expected that old and even new symptoms will arise as part of the healing process. Although this doesn't?t usually happen with VortexHealing and all services performed by Lisa Ferrer, occasionally it does. It is all part of the healing process.
I agree that I have read and understood the above paragraph and agree that the VortexHealing practitioner is not responsible for any individual symptoms that may arise as a result of receiving VortexHealing treatments and any services performed by Lisa Ferrer. I agree to take personal responsibility for whatever physical or emotional symptoms may arise as part of the healing processes of receiving VortexHealing treatments and any services performed by Lisa Ferrer , as well as to take responsibility for seeking medical treatment when I perceive it is necessary. I understand that my VortexHealing practitioner/Lisa Ferrer is not a medical professional (unless he/she also holds such degrees) and that he/she neither practices medicine nor takes the place of medical treatment or evaluations, when needed.
I also agree that I am liable for full payment of any scheduled appointment/class unless I give notice of cancellation at least 24 hours beforehand.
I further agree that once a class or class series begins no refunds are give. Classes can be taken out of order at the teachers discretion.
Client signature: ___________________________________________
Print Name: _______________________________________________
Date: ____________________
Referred by: ________________________________________________
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