Contact Old - Frontier Healing Energetics

Name *

First

Last

Email *

Phone

Height *

Weight *

Date of Birth *

Marital Status *

Do you have children? *

Yes
No

If so, how many?

Ages?

How would you describe your current health status? *

Are you seeking help for: (circle one or all of the below) *

Physical
Mental
Emotional
Spiritual

Have you been diagnosed by a medical doctor? *

Yes
No

If NO, what was your reason for not seeking medical advice?

What was the diagnosis?

Have you been prescribed a treatment plan?

What is the status of your treatment plan?

What are the outcomes you have achieved so far from the prescribed treatment plan?

Are these the outcomes you were hoping for?

Yes
No

If NO, what is your desired outcome?

Are you currently using medication for any of the following? (Prescription or OTC) *

Please provide any additional information you may feel is relevant to the previous question.

Do you have experience with any forms of alternative healing? (Acupuncture, chiropractic, naturopathic, homeopathic, massage, meditation, etc.) *

Yes
No

If YES, Please provide a brief description of your experience with alternative healing methodologies:

Do you suspect that your illness is sending a message that you need to make a change in your life? *

Yes
No

If YES, what message is it sending? (slow down, increase your emotional honesty, spend more time with loved ones, etc.)

Do you suspect that the root cause is: *

Do you think your body has the ability to heal itself from something minor? *

Yes
No

Please describe:

Do you think your body has the ability to heal itself from something major? *

Yes
No

Please describe:

Is there anything noteworthy going on in your life that you suspect may be having either a positive or negative effect on your illness? *

Family Life
Business Life
Social Life

Briefly describe:

Do you feel you have all of the resources you need to help you overcome your condition? *

Yes
No

If ‘No’ - what resources would you like for me to add to your healing process?

Have you ever experienced physical, mental, emotional, psychological, or spiritual trauma? *

Yes
No

If so, can you remember when and where? (Briefly describe.)

To the best of my knowledge, I believe the information given is true and correct. *

Check if you agree

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