Please print and fill out this New Client Intake form prior to your appointment. Scan or take a photo of the completed form an email it back at least 5 days in advance to [email protected]. If the form is received the day of our meeting, we may need to spend time reviewing it, which takes time away from your healing session.
Your healing sessions will consist of a quick introduction before we start and a wrap-up afterwards. We appreciate you taking the time to review this information. Complete the enclosed form and supply me with the items requested below.
CANCELLATION POLICY
If you need to reschedule or cancel your appointment, please notify us at least 24 hours in advance to avoid a cancellation fee. Any sessions cancelled within 24 hours, will incur the full session fee. Cancellation fees will be 1/2 of the session cost.
☐ ___________________________________
By placing an “x” in the box above and entering your name, you agree to the Cancellation Policy for this session and future sessions. This is required for any and all sessions booked.
INFORMED CONSENT FORM
The United States of America currently has no licensing policy in regard to Sound or Energy Healing, and Cuseami is not a licensed Medical Doctor or therapist. I do not deal with drugs, nor do I issue a diagnosis or suggest cures.
My purpose is simply to provide a safe space for my client to experience healing through natural processes. I consider the use of sound, energy, herbs, essential oils, crystals and any other natural healing modality as a way to encourage the body to get back to optimal functioning and everyone reacts to these methods individually. I make no claims for their medicinal actions, nor do I cite scientific evidence. Any information offered is done so on the basis of personal experience and traditional uses.
My clients agree to make their own choices as to what they do with the healing material they have been offered and are solely responsible for their own decisions and actions. It is always my recommendation to seek out the advice of a licensed health care professional whenever you feel it is necessary in regard to your own personal health, especially with serious conditions. Clients may need to consult with their physician and get approval to attend healing sessions if you have metal in their bodies, suffered concussions, have a pacemaker, use an insulin pump, and the like, or if you are pregnant. If in doubt, consult your physician before our time together.
Some issues such as suicidal thoughts or late-stage cancer are beyond the scope of my expertise, and I would advise you to seek outside help.
I understand that:
I agree to:
WHAT TO EXPECT:
In general, a typical session begins with a short assessment to discuss your concerns, thoughts or questions. During the session you can choose to sit or lay down. While we try to make you as comfortable as possible, if you have specific needs, please bring your own pillow or blanket, etc. We make every effort to assure that our clients feel safe and comfortable.
We may work on your body or above your body, so please let me know if there are any areas that you do not want work done. If you do not wish to be touched, please let me know. My work is intuitive, and I feel the energy and work where the energy is stagnant, deficient, stuck or unbalanced.
You may feel many different results such as heat or cold, shivers, nausea, headache, relaxation, release, relief, etc. You may also feel nothing at all. Any reactions can happen immediately or even months later. No reaction is positive or negative, it purely is. It may mean something to you right away or it could be a mystery for a while. Both are normal. I find that energy medicine has a cumulative effect, so when you treat yourself to regular sessions, better health and well-being are natural outcomes. At the end, we will check in about anything that came up for you during the session.
I have read the above statements and I understand and agree with them. My purpose to seeking the advice of Cuseami is to do so for educational purposes only.
I understand that Cuseami does not diagnose illness, disease, or mental disorder. Nor does he
prescribe medical treatment or pharmaceuticals. It has been made clear that my session is not a substitute for medical examination or diagnosis and that it is recommended that I see a medical doctor for any physical or mental ailment that is not addressed in my session.
I agree that Cuseami will not be held liable for any problems that might arise that I believe might be attributed to the energy healing season. I have stated all of my known medical
conditions to Cuseami and if necessary, I will keep him updated on my physical, mental, and emotional health. I acknowledge that Cuseami practices for the purpose of providing mental/emotional/physical and spiritual support using multiple techniques. I attest that I understand the nature of the session and freely elect to receive the techniques. I release Cuseami from any and all claims of malpractice, non-disclosure, or lack of informed consent.
☐ ______________________________________
By placing an “x” in the box above and entering your name, you agree to the Informed Consent.
Please know that tis and any subsequent sessions are purely confidential and none of your information will be shared with anyone.
Cuseami (Joe Arnold)
HEALTH PROFILE
Name: __________________________________________________ Age: _______
Phone #: __________________________(CELL#) ____________________________
Preference: ☐ Home ☐ Cell
Full mailing address:___________________________________________________
E-mail Address: _______________________________________________________
Date of Appointment: _____________________ Day of Week:_______________
Time:__________________________
What is your current health goal/what do you hope to get out of this session?
AREAS OF CONCERN:
In this section, list your main issues and rate them by severity on a scale of 1-10, with 10 being the most severe.
Please note that we will address as many issues as possible, but it’s often best to deal with fewer at a time. This is why booking multiple sessions is important.
Issue
Severity
What do you believe is/are the cause(s) of these issues?
What have you done thus far to help alleviate these issues?
Are you currently under the care of a physician? If so, what for?
What are your most pressing current physical and emotional health issues (acute and chronic)?
Any past accidents? Operations?
Do you have any specific spiritual practice?
Anything else you think I should know?
Allergies
Do you have allergies?
☐No
☐Yes, to what?
Medication or herb allergies?
☐No
☐Yes, to what?
Food allergies
☐No
☐Yes, to what?
Sensitive Skin?
☐No
☐Yes, to what?
Emotional Checklist
Put an X next to each statement that corresponds to the way you often feel.
☐ Anxiety and feeling overwhelmed or stressed, especially anxiety felt in the body, or physical anxiety
☐ Feeling worried or fearful
☐ Have intrusive thoughts, have an overactive brain, or have unwanted thoughts – especially thoughts about unpleasant memories, images or worries
☐ Panic attacks
☐ Unable to relax or loosen up
☐ Stiff or tense muscles
☐ Feeling stressed and burned-out
☐ Obsessive thoughts or behaviors
☐ Perfectionism or being overly controlling
☐ Irritability
☐ Winter blues or seasonal affective disorder
☐ Negativity or depression
☐ Excessive self-criticism
☐ Craving carbs, alcohol, or drugs for relaxation and calming
☐ Low self-esteem and poor self-confidence
☐ PMS or menopausal mood swings
☐ Hyperactivity
☐ Anger or rage, agitated easily or irritated
☐ Digestive issues
☐ Fibromyalgia, temporomandibular joint syndrome, or other pain syndromes
☐ Difficulty getting to sleep
☐ Insomnia or disturbed sleep
☐ Lack of energy
☐ Lack of focus
☐ Lack of drive and low motivation
☐ Attention deficit disorder
☐ Heightened sensitivity to emotional pain
☐ Heightened sensitivity to physical pain
☐ Crying or tearing up easily
☐ Eating to soothe your mood, or comfort eating
Your healing sessions will consist of a quick introduction before we start and a wrap-up afterwards. We appreciate you taking the time to review this information. Complete the enclosed form and supply me with the items requested below.
CANCELLATION POLICY
If you need to reschedule or cancel your appointment, please notify us at least 24 hours in advance to avoid a cancellation fee. Any sessions cancelled within 24 hours, will incur the full session fee. Cancellation fees will be 1/2 of the session cost.
☐ ___________________________________
By placing an “x” in the box above and entering your name, you agree to the Cancellation Policy for this session and future sessions. This is required for any and all sessions booked.
INFORMED CONSENT FORM
The United States of America currently has no licensing policy in regard to Sound or Energy Healing, and Cuseami is not a licensed Medical Doctor or therapist. I do not deal with drugs, nor do I issue a diagnosis or suggest cures.
My purpose is simply to provide a safe space for my client to experience healing through natural processes. I consider the use of sound, energy, herbs, essential oils, crystals and any other natural healing modality as a way to encourage the body to get back to optimal functioning and everyone reacts to these methods individually. I make no claims for their medicinal actions, nor do I cite scientific evidence. Any information offered is done so on the basis of personal experience and traditional uses.
My clients agree to make their own choices as to what they do with the healing material they have been offered and are solely responsible for their own decisions and actions. It is always my recommendation to seek out the advice of a licensed health care professional whenever you feel it is necessary in regard to your own personal health, especially with serious conditions. Clients may need to consult with their physician and get approval to attend healing sessions if you have metal in their bodies, suffered concussions, have a pacemaker, use an insulin pump, and the like, or if you are pregnant. If in doubt, consult your physician before our time together.
Some issues such as suicidal thoughts or late-stage cancer are beyond the scope of my expertise, and I would advise you to seek outside help.
I understand that:
- An assessment will be conducted to determine the general health of my energy system
- Any suggestion made by Cuseami will be to assist my body’s natural ability to achieve a balanced state, to the extent that my body or my highest knowing will allow.
- The goal of my session will be identified as part of the initial process and that I will have input as well as give intent and permission for it.
- These sessions are not meant to replace treatment with established medical practices yet can be complementary to them.
- There are no guarantees as to the results of treatment
- Cuseami is not a licensed physician and will neither diagnose nor prescribe any condition nor does she make any specific claims regarding results from the sessions that I receive. Nothing in the work (your name) does is considered the practice of medicine.
I agree to:
- Raise any questions or concerns about anything I do not understand.
- Consider any suggestions that the practitioner may raise concerning referrals to other health care practitioners, homework, or my desired focus/introspection.
- Take full responsibility for my own health care.
- Give consent to Cuseami to conduct a session to balance my energy system. I acknowledge that this could involve touch, and I can request otherwise.
WHAT TO EXPECT:
In general, a typical session begins with a short assessment to discuss your concerns, thoughts or questions. During the session you can choose to sit or lay down. While we try to make you as comfortable as possible, if you have specific needs, please bring your own pillow or blanket, etc. We make every effort to assure that our clients feel safe and comfortable.
We may work on your body or above your body, so please let me know if there are any areas that you do not want work done. If you do not wish to be touched, please let me know. My work is intuitive, and I feel the energy and work where the energy is stagnant, deficient, stuck or unbalanced.
You may feel many different results such as heat or cold, shivers, nausea, headache, relaxation, release, relief, etc. You may also feel nothing at all. Any reactions can happen immediately or even months later. No reaction is positive or negative, it purely is. It may mean something to you right away or it could be a mystery for a while. Both are normal. I find that energy medicine has a cumulative effect, so when you treat yourself to regular sessions, better health and well-being are natural outcomes. At the end, we will check in about anything that came up for you during the session.
I have read the above statements and I understand and agree with them. My purpose to seeking the advice of Cuseami is to do so for educational purposes only.
I understand that Cuseami does not diagnose illness, disease, or mental disorder. Nor does he
prescribe medical treatment or pharmaceuticals. It has been made clear that my session is not a substitute for medical examination or diagnosis and that it is recommended that I see a medical doctor for any physical or mental ailment that is not addressed in my session.
I agree that Cuseami will not be held liable for any problems that might arise that I believe might be attributed to the energy healing season. I have stated all of my known medical
conditions to Cuseami and if necessary, I will keep him updated on my physical, mental, and emotional health. I acknowledge that Cuseami practices for the purpose of providing mental/emotional/physical and spiritual support using multiple techniques. I attest that I understand the nature of the session and freely elect to receive the techniques. I release Cuseami from any and all claims of malpractice, non-disclosure, or lack of informed consent.
☐ ______________________________________
By placing an “x” in the box above and entering your name, you agree to the Informed Consent.
Please know that tis and any subsequent sessions are purely confidential and none of your information will be shared with anyone.
Cuseami (Joe Arnold)
HEALTH PROFILE
Name: __________________________________________________ Age: _______
Phone #: __________________________(CELL#) ____________________________
Preference: ☐ Home ☐ Cell
Full mailing address:___________________________________________________
E-mail Address: _______________________________________________________
Date of Appointment: _____________________ Day of Week:_______________
Time:__________________________
What is your current health goal/what do you hope to get out of this session?
AREAS OF CONCERN:
In this section, list your main issues and rate them by severity on a scale of 1-10, with 10 being the most severe.
Please note that we will address as many issues as possible, but it’s often best to deal with fewer at a time. This is why booking multiple sessions is important.
Issue
Severity
What do you believe is/are the cause(s) of these issues?
What have you done thus far to help alleviate these issues?
Are you currently under the care of a physician? If so, what for?
What are your most pressing current physical and emotional health issues (acute and chronic)?
Any past accidents? Operations?
Do you have any specific spiritual practice?
Anything else you think I should know?
Allergies
Do you have allergies?
☐No
☐Yes, to what?
Medication or herb allergies?
☐No
☐Yes, to what?
Food allergies
☐No
☐Yes, to what?
Sensitive Skin?
☐No
☐Yes, to what?
Emotional Checklist
Put an X next to each statement that corresponds to the way you often feel.
☐ Anxiety and feeling overwhelmed or stressed, especially anxiety felt in the body, or physical anxiety
☐ Feeling worried or fearful
☐ Have intrusive thoughts, have an overactive brain, or have unwanted thoughts – especially thoughts about unpleasant memories, images or worries
☐ Panic attacks
☐ Unable to relax or loosen up
☐ Stiff or tense muscles
☐ Feeling stressed and burned-out
☐ Obsessive thoughts or behaviors
☐ Perfectionism or being overly controlling
☐ Irritability
☐ Winter blues or seasonal affective disorder
☐ Negativity or depression
☐ Excessive self-criticism
☐ Craving carbs, alcohol, or drugs for relaxation and calming
☐ Low self-esteem and poor self-confidence
☐ PMS or menopausal mood swings
☐ Hyperactivity
☐ Anger or rage, agitated easily or irritated
☐ Digestive issues
☐ Fibromyalgia, temporomandibular joint syndrome, or other pain syndromes
☐ Difficulty getting to sleep
☐ Insomnia or disturbed sleep
☐ Lack of energy
☐ Lack of focus
☐ Lack of drive and low motivation
☐ Attention deficit disorder
☐ Heightened sensitivity to emotional pain
☐ Heightened sensitivity to physical pain
☐ Crying or tearing up easily
☐ Eating to soothe your mood, or comfort eating
You are welcome to copy and print this form on your computer, scan it or take a picture on your phone and send it to me in an email or text.
