Client Intake Form

 
I, the client, am committing whole heartedly to the greater expansion of my life. I am worthy of my dreams - those given to me by the divine. I accept that all my resources are here for me now. I work diligently daily to allow for my brightest self to shine on Earth. I make a difference to all who see me.
Name *
Name
Address
Address
Phone *
Phone
Can we add you to our newsletter? *
Emergency Contact Name *
Emergency Contact Name
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
Ms. Knowles’ Background/Credentials/Trainings *
Soul Integration Certified Practitioner, by the Theo Group Pangu Shengong Certified Teacher of the Moving Form Practice Ordained Minister by The Universal Light
Fees/Payment Policy *
Packages must be used within 6 months of purchase to be valid. There are no refunds on sessions that have expired. Cash, Checks, Pay Pal or Credit Cards are acceptable forms of payment. Cancellations must be given 48 hours before appointment or the full session rate will be billed.
Confidentiality *
Your sessions are always held in confidence with the highest level of respect and integrity. Professional Ethics and Tennessee State Law indicates that the client controls confidential information, meaning your sharing will be held in confidence. The only exception to this law is if we believe a client could hurt himself, herself, or another individual, as well as, any reports of child or elderly abuse. These are required by law to be reported to the Department of Human Services.
Benefits & Considerations *
When you set out to make your life better, generally, the way you used to live changes. It requires a new set of emotions, attitudes, behaviors, and perspective on a situation. Your self-esteem, sense of self, relationships, job and connection to community can all change for the better. Unfortunately, we cannot guarantee a specific outcome for each client. It is ultimately is up to you how your life unfolds from here. During your session, there may be suggestions to see other practitioners, such as nutritionist, psychologist, qi gong instructors, additional energy healers or other practitioner to compliment your session. These are suggested to help enhance and quicken the progress on a specific issue you have discussed with Ms. Knowles. These are only suggestions and ultimately up to you to prioritize.
Emergency *
If you need us, please call 615-807-0792. Our private session hours are Monday, Thursday, Friday and Saturday 10 am – 5 pm (CST). If you need to leave a message, please allow 24 hours for a response. If you are experiencing an emergency that is life threatening, call 911. If you are in crisis, please call the Crisis Help Line in your area (In Tennessee 855-274-7471) or go to the nearest emergency room.
I have read and understood the nature of this practice. I freely elect to receive private sessions from Lori Knowles Energy Healing. I, the client, release Lori Knowles and the energy healing practice from any and all claims of malpractice, nondisclosure, or lack of informed consent. I, the client, freely assume any and all risks from these sessions. The information contained in this the private session is educational. It does not provide (nor is it intended to be a substitute for) professional medical or psychological advice, diagnosis or treatment.