Health Information Form | Healing Earth Therapy

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Health History Form

Emergency Contact (Name & Phone Number)

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

List any medical conditions, injuries, traumas, illnesses, or medications which are currently affecting you

What are you wanting to recieve in your treatment?

Relaxation and stress relief

Reiki energy balancing

Friction work for scar tissue/adhesions in fascia

Fire Cupping for muscle, fascia and Qi relief

Fire Cupping for detoxification of the body and Qi

Shamanic Divination (spiritual insight)

Psychopomp to release suffering spirits from your body or home

Shamanic power transfer (large amount of energy for your healing and life)

Meet your spirit helpers

Esoteric Acupressure to bring your souls consciousness into your human consciousness

What areas of life would you like to improve upon to create wellness?

How did you hear about us?

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