Confidential Client Information Forms
Energy Healing Work and Frequency-Specific Microcurrent Treatments

To provide you with the best possible experience, please fill out this form completely and honestly. Some of this information is recommended by practitioner organizations and some is required by U.S. health-governing organizations.

All your information is strictly confidential and its privacy is governed by HIPAA, the U.S. Health Insurance Portability and Accountability Act of 1996.

Please note that I am currently using only Distance Healing Sessions in my practice; there is no physical practitioner space where we meet in person. If you have concerns about this, please Contact Me or check out My Reviews to see what others are saying.

– Beth

Please open and complete the form that applies to the session type that we will be having.

Intake Form for Quantum Energy Healing Sessions

Full Name *

First

Last

Date of Birth *

Contact Information

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Emergency Contact *

Emergency Contact Phone

Current Occupation(s)

How Did You Hear About Me?

What Type of Energy Sessions, if Any, Have You Received in the Past?

Past Energy Sessions

Reiki
Sound
Crystal

Other Type of Energy Session(s)

A Few Medical Details

Implanted Surgical Devices

I have a surgical implant.

Current Medical Conditions Being Treated

Medications and Supplements

What Concerns Do You Have That Energy Healing May be Able to Help Address? Be Detailed and Specific.

WHAT ENERGY HEALING IS, WHAT IT IS NOT, AND WHAT TO EXPECT

I incorporate different techniques of energy healing in my practice, driven by client needs and what I hear to do from spirit. Some of these techniques are formalized practices, and some are part of what I personally bring to a session. Here are two formalized techniques that I am certified to practice:

Reiki is a spiritual healing art with its roots in Japanese practices. It is not a massage technique, nor is it based on belief or suggestion; instead, it is a subtle, effective form of energy work using Spiritually-Guided Life Force Energy.

Theta Healing® is a meditational process that creates physical, psychological, and spiritual healing with focused prayer through the Creator. When we connect to the Creator of all that is, our brain waves automatically go into a Theta state of mind. In this state, you can create anything and change reality.

Energy healing, in all its forms, promotes healing of the energetic body that exists in all of us. This energetic body exists simultaneously with our physical body, with each having a direct effect on the other. Energy healing therapies can help us mentally, spiritually, emotionally, and physically, including:

Relief from stress and anxieties by balancing the energetic structures, the Chakras, throughout the body.
Detecting and removing energy blocks that may be at the root of physical, mental, and emotional stresses.
Complementing and possibly enhancing traditional medicinal healing therapies and rehabilitation.
Clearing the mind for effective decision-making and being at peace with situations.
Increasing intuition for, and sensitivities to, the world around us.

No energy healing practice is a substitute for established medical care. It has been shown that energetic healing arts can complement and enhance the effectiveness of medical treatments, and you are strongly encouraged to continue all treatments and medications provided to you by a physician.

Remain as relaxed as possible after your session. Drink lots of water and eat natural, unprocessed foods to help balance your physical energy levels. You may notice a shift in your sleeping pattern, leaving you tired or energized. You are encouraged to journal your experiences and share them with your practitioner at your next session to help make slight course corrections to your line of treatment. Reach out to your practitioner with any questions or concerns that you have.

DISCLAIMER, WAIVER AND RELEASE

The following statements refer to the professional practice of Beth A. Pfeffer, Angelic Soup, LLC., its owners, partners, successors, lessors, employees, and assigns; hereinafter referred to, individually or collectively, as Energy Healing Practitioners.

By providing my electronic signature below, I hereby accept, understand, and confirm that Energy Healing Practitioners do not diagnose illness, disease, or mental disorders, nor do they prescribe medical treatment or pharmaceuticals. I also affirm that it has been made clear to me that the practice of Energy Healing is not a substitute for medical examination, diagnosis, or treatment, and that it has been recommended to me that I consult with a medical practitioner such as an M.D. or N.D. for any physical or mental ailment that I may be currently experiencing or may experience in the future.

Consequently, I agree and affirm that Energy Healing Practitioners cannot be held liable for any problem, real or imagined, that might arise as a result of participating in Energy Healing sessions. I also affirm that I have provided a true and complete representation of my physical, emotional, and mental health by way of disclosure above and will update such information with my practitioner as conditions change or as necessary.

I understand and affirm that Angelic Soup, LLC., its owners, partners, successors, lessors, employees, and assigns hereby disclaim any and all representations of efficacy for any treatment(s), specific outcomes, or results. I agree to release, indemnify, and hold harmless Angelic Soup, LLC., its owners, partners, successors, lessors, employees, and assigns from any claims of injury, malpractice, non-disclosure, or lack of informed consent.

I furthermore affirm that I understand the nature of the treatments imagined by Energy Healing practices and freely elect to receive those treatments. I agree that I have been given enough opportunity to ask questions and make specific requests to make my treatment time as comfortable as possible. Lastly, I agree to abide by all policies set forth by Angelic Soup, LLC., and/or its lessors. For in-person sessions, I agree to abide by all sanitary and safety provisions that are mandated by authorities and set forth by Angelic Soup, LLC.

Signature Full Legal Name *

Signature Verification

By checking this box, I hereby cause my signature to be affixed to this form as if I had signed it in person.

Distance Session Confirmation *

I acknowledge that Beth's sessions are done as Distance Healing Sessions over the phone and not in a physical practitioner space.

Intake Form for Frequency-Specific Microcurrent Treatments

Full Name *

First

Last

Date of Birth *

Contact Information

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Emergency Contact *

Emergency Contact Phone

Current Occupation(s)

How Did You Hear About Me?

Medical Conditions

Pregnancy

I am or may be pregnant.

Implanted Surgical Devices

I have a surgical implant.

Seizures

I have experienced seizures

Blood Clots

I've had blood clots

Please provide any more detail you would like concerning the above conditions.

Other Medical Conditions for which you are being treated.

Medications and Supplements that you take on a regular basis.

WHAT FSM IS AND WHAT TO EXPECT FROM TREATMENTS

Frequency-Specific Microcurrent technology (FSM) is a healing modality with origins in the early 1900's. It uses an electronic device to generate pairs of low-frequency micro-ampere currents that can be applied to the patient's skin using graphite gloves, conductive gel pads, wet towels, or electrical coils that send pulsed electromagnetic fields.

As an energy-based healing modality, FSM, like Reiki, has a distance healing component that allows the practitioner and the patient to be in separate locations during the treatment. Efficacy of the treatments does not depend on how the treatment is delivered to the patient.

How FSM Works. FSM employs biological resonance and frequencies that seem to change cell signaling and thereby change cell function and structures to reduce pain and improve function. It also increases adenosine triphosphate (ATP), an organic compound in the body's mitochondria that synthesizes energy to drive and support processes such as muscle contraction, nerve impulse propagation, condensate dissolution, and chemical synthesis. FSM has also been shown to increase pain-relieving endorphins and decrease prostaglandins, inflammatory substances that are usually elevated in chronic pain conditions.

Hydration is Critical for FSM. More than half (60%) of the human body is water. FSM is transmitted through the water of the body to reach the cells under treatment. Consequently, being fully hydrated is absolutely essential for the process to work as it should. Here's what that means:

Over the course of 2 hours before treatment, drink a minimum of 16 ounces of water.
Drink only water for this requirement, and it's better to avoid diuretics like caffeine.
Do not guzzle, this creates bladder pressure and the water is not adequately absorbed through the intestines.
Sip your water over time. Drink a couple of swallows every 10 minutes or so to allow good absorption.
After treatment, drink another 32 ounces or more of water throughout the rest of the day to flush toxins released by the treatment.

INFORMED CONSENT, WAIVER, AND RELEASE

By this instrument, I hereby give permission to Practitioner to treat specific conditions or ailments that are detailed on this Intake Form using Frequency Specific Microcurrent ("FSM") treatments.

By providing my electronic signature below, I hereby accept, understand, and confirm that Practitioner does not diagnose illness, disease, or mental disorders, nor prescribe medical treatment or pharmaceuticals. I also affirm that it has been made clear to me that the practice of FSM Treatments is not a substitute for medical examination, diagnosis, or treatment, and that it has been recommended to me that I consult with a medical practitioner such as an M.D. or N.D. for any physical or mental ailment that I may be currently experiencing or may experience in the future.

I acknowledge that FSM is an energetic technological treatment that does not use drugs or any physical manipulation of the body. Consequently, there may be certain conditions or ailments for which FSM is contraindicated. While there are studies showing benefits with FSM treatments, FSM is not routinely used in conventional medical care.

I agree and affirm that Practitioner cannot be held liable for any problem, real or imagined, that might arise as a result of participating in FSM Treatments or Energy Healing sessions. I also affirm that I have provided a true and complete representation of my physical, emotional, and mental health by way of disclosure above and will update such information with my practitioner as conditions change or as necessary.

I further acknowledge that, although exceptionally rare, there may be side effects to FSM treatment, such as nausea, fatigue, drowsiness, a temporary increase in pain, or a flu-like feeling from the sudden release of toxins that have accumulated in the tissues and potentially contributed to the ailment. If side effects occur, it is usually within the first 90 minutes after treatment and can last from 4 to 24 hours.

I understand and affirm that Practitioner, its owners, partners, successors, lessors, employees, and assigns hereby disclaim any and all representations of efficacy for any treatment(s), specific outcomes, or results.

I furthermore affirm that I understand the nature of the treatments imagined by FSM and Energy Healing practices and freely elect to receive those treatments. I agree that I have been given enough opportunity to ask questions and make specific requests to make my treatment time as comfortable as possible. Lastly, I agree to abide by all policies set forth by Angelic Soup, LLC., and/or its lessors.

I hereby grant Practitioner the right to alter or discontinue treatments, as warranted by the situation, at the sole discretion of Practitioner. I acknowledge that I have the right to discontinue treatments at any time and for any reason, either during a session or before my next scheduled visit.

I agree to indemnify and hold harmless Practitioner, assistants, caregivers, Angelic Soup, LLC., its successors, assigns, partners, owners, officers, and representatives, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including court costs and attorney’s fees brought about as a result of actual or perceived harm resulting from FSM treatments.

Signature Full Legal Name *

Signature Verification

By checking this box, I hereby cause my signature to be affixed to this form as if I had signed it in person.

Contact Beth

Email Beth at

beth@angelicsoup.com

Or fill out the Contact Form here