New Client Intake Form • Remote Energy Therapy

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By Providing your email address you are giving us; Energy Heals, LLC, Express Permission to send you emails from time to time notifying you of Policy Changes, Rate Changes, Schedule Changes, or any other special event. We will never sell your email address! When you receive an email from us you will have the opportunity to Opt-Out, if you so desire.

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How did you hear about Jim?

What health concern(s) are you experiencing currently? *

What actions have you taken to resolve the above concerns? *

What would be your ideal outcome for the concern(s) listed? *

Please list any medications you are currently taking: *

Please list any vitamin and mineral supplements you are currently taking: *

Please list any past medical conditions that you have had: *

Do you experience stress? *

Did you take the COVID 19 Vaccine? *

Please add any information that you feel that you would like to share with me:

Optional: Email me occasional bulletins from RemoteEnergyTherapy.com

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