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:
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.
None of the information on this website or services given by Lisa Ferrer is intended to replace medical and psychiatric advice. Consult your physician for all matters pertaining to your health and whenever you embark on a new or different health plan.
Journey to Joy, Physcal Journey, Emotional Journey, Spiritual Journey, Professional Journey, Professional Certification For Healers, Dreams, VortexHealing, Manifesting, Reiki, Ear Candeling, Ear Coning, Chakra, Chakras, Psychic, Intuitive Development, Meditation, Hypnosis, NLP, Life Regression.