Client Intake Form

Clear Path Energy Healing
Mary L. Benner, MA, EEM-AP

Today's Date

Basic Information

Your Name

Your Email

Your Phone

Address

City

State

Zip Code

Employment Information

Occupation

Work Phone

Emergency Contact

Name

Phone(s)

Relationship to You

PLEASE LIST THE NAME and specialties of other health care professionals you are currently seeing, as well as the name of your primary physician.

Please Read Carefully Before Submitting

I understand that the energy healing sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner.

I further understand that energy healing should not be construed as a substitute for needed medical attention. Energy healing practitioners do not diagnose, treat, or prescribe for medical conditions. Energy healing brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting the more subtle energies described in other cultures with terms such as chakras, meridians, and etheric fields.

By electronically signing and submitting this form, I agree to share this information with Clear Path Energy.
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