Date
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MM
DD
YYYY
Name
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First Name
Last Name
Name or nickname you prefer if other
Preferred pronouns?
City, State/Province, and Country
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Best phone number for me to call you on at appointment time? I can also Skype (audio only) for free calling locally and internationally.
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(###)
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Cellular number for texting?
(###)
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Your email address
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What is your profession(s)?
Age
How did you hear about me?
Have you experienced distance healing or energy work before?
Briefly explain your exercize/fitness regimen.
Briefly explain your spiritual, philisophical, or religious orientation.
What are the major stressors in your life?
Are you currently working with a therapist or counselor?
Are you currently under a physician's care for medical conditions? Please explain.
What do you whant to change or improve with this treatment?
Have you been experiencing any of the following during the past year?
Other health conditions not listed above.
Are you currently taking percription medications?
Do you currently have any of the following?
Is there anything else you think may be important or helpful for me to know?
I agree to give at least 24 hours notice should I need to cancel or reschedule a session, and pay for sessions cancelled or missed without such notice.
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Terms and Conditions
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Ko Darlington is not a licensed medical doctor nor licensed psychologist and does not practice any form of licensed medicine or psychology. He does not diagnose, cure, heal, treat disease or prescribe medication. He will not be held responsible for any damages or losses. It is recommended that clients continue to seek the advice of a licensed physician for medical conditions.
