Rapid Energy Releasing

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• No

Primary Concerns – Please list 3 concerns and give them a level from 1-10. 1 being hardly notice symptoms and 10 being symptoms are unbearable:

Please list medications/remedies/supplements and reasons for taking:

Please list any significant accidents/injuries:

Please tick any conditions that apply:

• CANCER
• VARICOSE VEINS
• ALLERGIES
• HEART DISEASE
• H/L BLOOD PRESSURE
• SURGERY
• DIABETES
• PARALYSIS
• GENETIC DISORDERS
• STROKE
• TMJ DYSFUNCTION
• PHOBIAS
• EPILEPSY
• ARTHRITIS

Please tick any symptoms that you experience:

• HEADACHE
• HEAVY FEELING IN LIMBS
• COLD IN HANDS AND FEET
• FAINTNESS/DIZZINESS
• BLURRINESS OF VISION
• LOWER BACK PAIN
• TIGHTNESS IN JAW
• CONSTIPATION
• SHOULDER/NECK PAIN
• WEAK BODY PARTS
• LOOSE BOWEL MOVEMENTS
• CARPEL TUNNEL SYNDROME
• SMOKING
• IRRITATED BOWEL
• MENSTRUAL IRREGULARITIES
• NERVOUSNESS
• PAINS IN HEART/CHEST
• POOR APPETITE
• INDIGESTION
• EXCESSIVE URINATION
• INSOMNIA
• GRINDING OF TEETH FATIGUE
• PREGNANT

OTHER (please state)

If you smoke, how many times a day to you smoke?

Please tick any areas you would like to see an improvement in:

• NEGATIVE SELF-TALK
• SELF-SABOTAGE
• ABILITY TO REACH IDEAL WEIGHT
• ABILITY TO TAKE ACTION
• INCREASE LEARNING ABILITY
• BELIEF IN ABILITY TO ACHIEVE GOALS
• PERSONAL MAGNETISM
• BENEFICIAL, RELATIONSHIPS
• STRENGTHEN MEMORY/CONCENTRATION
• PROSPERITY (ATTRACT WHAT YOU CHOOSE)
• ABILITY TO RELAX
• ABILITY TO USE DREAMS AS MENTAL TOOL FOR PROBLEM SOLVING
• BREAKING OLD HABITS
• ATTITUDE AND SKILLS AT WORK
• RELEASE NEGATIVE EVENTS
• SELF-ESTEEM
• ABILITY TO ALIGN BODY/MIND FOR SELF-HEALING
• YOUTHFUL VITALITY
• ELIMINATE PROCRASTINATION

Below, please describe what you would like to accomplish with these treatments:

I consent to treatment for myself (or my minor child), and understand that the services provided by the practitioner Rachel Farnsworth is intended to enhance relaxation and increase communication within my body. I understand that these services are not a substitute for medical treatment or medications.I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan. I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner Rachel Farnsworth will have access to information in my file to enhance my healing. I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner Rachel Farnsworth and the facility/location where the services are provided. I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for distance sessions, should I request them. *

• I agree

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