Free Spirit School of Integrated Energy Healing Student Application Form


Name:_______________________________________

Address: _____________________________________

City/State/Zip code:____________________________

Home Phone:______________ Work Phone:____________

Cell Phone: _______________

Birthday (month/day)_____________

Email:_________________Fax#________________

The following questions are necessary for you to complete in order to be considered for acceptance into the program. All information that you share is kept confidential.


1. In a brief statement please share why you are interested in
attending the Free Spirit School of Integrative Energy Healing
Program:




2. Please list all medical conditions:





3. Please list all medications and over the counter products you are
currently taking. Include vitamins and supplements.




4. Do you have any special needs? YES OR NO (circle one) If yes, please specify:



5. Please check the usage and frequency of the following:

Alcohol: ___None
___1-2 times per week
___2-3 times per week
___4 or more times per week
___Daily

Tobacco: ___None
___1-2 times per week
___2-3 times per week
___4 or more times per week
___Daily-specify quantity______________________

Recreational Drugs: ____None
____1-2 times per week
____2-3 times per week
____4 or more times per week
____Daily

If you have checked usage please specify type and quantity:

______________________________________________________


6.Have you ever been treated for a mental or emotional condition or has there ever been a recommendation that you receive treatment?

YES OR NO (circle one) If yes, please specify:



7. Have you ever been treated for psychological difficulties or has there ever been a recommendation that you be treated for these difficulties? Please provide type and date.





8. Please list all therapeutic, spiritual or counseling groups in which you currently participate in for support and development:

______________________ _______________________

______________________ _______________________

______________________ _______________________




9. Provide a list and description of any type of training, certificates or degrees that you have earned:


______________________ _______________________

______________________ _______________________

______________________ _______________________





10. Do you have your own healing practice or other service oriented profession (e.g.. massage, nursing, Reiki, Physical or Occupational Therapy, etc.)? If yes, please specify:





The Free Spirit School of Integrative Energy Healing is not a licensed medical care service. The healing work you participate in is not a replacement for medical care. It is recommended that you openly discuss whatever services you participate in with your medical provider in order to facilitate optimum health and wellness. If you require the care of a licensed health care professional, please contact your state's medical and/or psychological board.

Initial: ___________

I hereby state that I have not been convicted of, entered a plea of nolo contendre, guilty of, or deferred adjudication to crimes or offenses of a moral or criminal nature within the past seven years. True or False (circle one)

Initial: ___________

I release the Free Spirit School of Integrated Energy Healing of any responsibility from psychical, psychological or spiritual conditions that may arise from participation in the programs, classes and activities.

Initial: ___________

I acknowledge that all the information on this form is accurate and true to the best of my knowledge. Yes or No (circle one)

Initial: ___________



____________________________ Date:____________

Signature


 

 

Send your completed application and fee to: