Questionnaire for First Visit to Healing Session

Interview Sheet for the Energy Healing, First Visit


Welcome to my energy healing session!

This form is for people who take my healing for the first time.

Healing is not only about clearing and charging your engery,
but it can re-construct your energy field, chakras, and a lot more.

Any torsion, leakage, damage of your energy is strongly connected with your patterns you create in relationship with other people, or what you believe about yourself, parents, partner, society, and world.

So, this interview sheet allows me to get to know you and know a little of your background to make it easier for me to start off the healing based on your energy patterns that creates your reality, including your health conditions.

This might be a bit too long, but please be patient and answer the questions below.
If you do not feel comfortable to answer some questions, or do not know your answer, you can skip.
But, I recommend you to fill out the form as much as possible.

This interview sheet also allows "you" to think about yourself once again before taking my healing.

Please take your time, and have this time be all yours to touch your own heart quietly, and connect to yourself deeply.




苗字必須
Last Name
名前必須
First Name
メールアドレス必須
Email address
メールアドレス(確認)必須
携帯電話番号必須
Phone #
App to contact me for healing必須
example: Phone, Skype, Zoom, LINE, WhatsApp
Indicate your phone number or ID of above answer必須
Sex
Occupation
example: teacher, engineer...
Blood Type
Family Structure
Number of Children
What do you need a healing for?
Tell me the reason why you decieded to take a healing session.
Any medicine or supplement you are taking currently?
Name them if applicable.
Are you currently taking medical treatment?
Indicate what for and what department of hospital if applicable.
How often do you drink?
How often/much do you smoke?
Have you experienced any accident or injury?
If yes, when? and what was its cause?
How was the condition and do you have any after effect?
Have you had any surgery, hospitalization?
If yes, when, for what reason, and on what cause?
Please select ones you currently have or you have experienced.
Other concerns regaring health
What are your thoughts/feeling about yourself?
What was your relationship with your father (figure) like?
Did you have a close relationship? Did you fight all the time?
What was your relationship with your mother (figure) like?
Did you have a close relationship? Did you fight all the time?
What do you feel/think/believe about your human relationship/connection with other people?
What would you like to get in the healing session?
Example: good understanding of myself, confidence
Tell me if you have specific topic you want to talk about in the healing session.
smtp06