Empty Mountain Institute

*Name

*Email

*Phone

*Zoom required for clinic

I am able to connect with Zoom

Confirm Day and Time (Pacific Time)

I am invited for Friday, June 7th, 2024
I am invited for Saturday, June 8th, 2024

Age

Are you currently under a doctor's care for any condition?

Yes
No

What kind of treatment or therapy (briefly)?

Are you open to exploring the Mental, Emotional and/or Spiritual aspects of healing?

Yes
No

Are you willing to spend some time doing Qigong prescription exercises?

Yes
No

*What would you like to get out of your session?

I am to my knowledge not pregnant.

agree

Is there anything else that you feel it is important for your therapist to know?

How did you find out about the clinic?

* I understand that the person who I will be working with is not a Medical Doctor and does not medically diagnose, treat or prescribe. I understand that this is a Medical Qigong student clinic that I am volunteering for and that information about this session might be shared anonymously as part of the student's learning experience.

Yes, I understand and agree