Step 1. Client Intake Form

PERSONAL INFORMATION

Name

First Name

Last Name

Phone

Date of Birth

YYYY

Occupation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred By / How did you hear about us?

Primary Reason for today's visit

Please briefly share what brought you here today.

MEDICAL HISTORY

Do you take any prescription drugs?

If Yes, Please Specify

If you currently take prescription drugs, please specify.

Do you have any history of contagious disease(s)?

If Yes, Please Specify

If you have any history of contagious disease, please specify.

Do you have a history of serious physical injury?

If Yes, Please Specify

If you have any history of serious physical injury or injuries, please specify.

Do you have a history of psychological disorder?

If Yes, Please Specify

If you have a history of any psychological disorder, please specify.

Are you currently pregnant?

For females that are currently pregnant or may be currently pregnant, please check "yes". For everyone else, please check "no".

If Yes, and Need to Specify

If needed, please explain.

Do you smoke?

Diet

DESCRIPTION FOR TODAY'S VISIT

What is/are your present complaint(s)/diagnosis?

How long have you had this complaint(s)/diagnosis? (Be specific)

Please describe any history that may have caused or is relevant to your current condition and/or symptoms.

Relevant Treatment

Please describe what treatments you have taken thus far for this present condition/symptoms or related to your current situation.

Using a scale from 0-10, please indicate the current level of symptoms and choose the number before the Pranic Healing Session.

Donation Commitment to Atlanta Pranic Healing Center

Please let us know your donation commitment, schedule of donation and duration of healing needed. Then we will send you a donation link in accordance to your request and schedule.

Donation Commitment

As your commitment is important in your healing process and energetic exchange, please let us know your donation amount you would like to commit to.

Donation Schedule Commitment

Please let us know what schedule of donation you would like to commit to.

Duration of Healing needed

Please let us know the duration of healing you would like to commit to.

Other Comments

Disclaimer:

I, the recipient, understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist a medical professional is to be consulted immediately. I hereby release the person(s) providing the Pranic Healing and the Pranic Healing organization from any liability as the result of the services received by me.

Please submit name as an electronic signature below.

First Name

Last Name

Step 2. Donation

Once you submitted your Intake Form, we will email you details of donation process. We look forward to our healing journey together.

Pranic Healing with Judy Yi

Experience Pranic Healing with Judy Yi

Judy Yi invites you to experience the foremost energy healing system called Pranic Healing. Pranic Healing helps physically, emotionally, psychologically in a deep way.

grandmaster choa kok sui, Founder of Modern Pranic healing

Tell us what you think!

We are constantly working to raise the bar on our services. If you have any questions or concerns about your experience, please let us know.

New Client Intake Form - APHC

Step 1. Client Intake Form

Step 2. Donation

Pranic Healing with Judy Yi

Tell us what you think!