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                                       Quantum Navigator                                                                                                                	
  
                                                                                                                                                                        	
  
                                                                                                                                                                               	
  
                                                                                             Client	
  Intake	
  Form	
  (Confidential)	
                                      	
  
                              	
  
	
  
Name:____________________________________________________________________________Date:___________________	
  
Address:____________________________________________________________________________________________________	
  
City:____________________________________________________	
  State:_________________________	
  Zip:_______________	
  
Date	
  of	
  Birth:_____________________________	
  	
  Place	
  of	
  Birth:________________________________________________	
  
Home	
  Phone:____________________________________Work	
  Phone:___________________________________________	
  
Female:____	
  	
  	
  	
  Male:____	
  	
  	
  	
  Married:____	
  	
  	
  Divorced:____	
  	
  	
  Widowed:____	
  	
  	
  	
  Single:____	
  	
  	
  Separated:____	
  
Occupation:_____________________________________	
  	
  Employer:______________________________________________	
  
Work	
  Address:_____________________________________________________________________________________________	
  
City:___________________________________________________	
  State:__________________________	
  Zip:________________	
  
Name	
  of	
  Spouse:______________________________________	
  DOB:___________________________	
  
Children’s	
  Names	
  &	
  Ages:_________________________________________________________________________________	
  
	
  
Email:______________________________________________	
  
Person	
  to	
  Contact	
  in	
  case	
  of	
  Emergency:_______________________________________________	
  
Home	
  Phone:____________________________________Work	
  Phone:______________________________________	
  
	
  


                         #	
  of	
  organs	
  removed	
                        	
                     Personal	
  Stress	
  1-­‐10	
                             	
  
                                            	
  
        #	
  of	
  synthetic	
  drugs	
  used	
  currently	
                   	
      #	
  of	
  sugar	
  type	
  products	
  in	
  a	
  day	
  1-­‐10	
        	
  
                                            	
  
                   #	
  of	
  times	
  you	
  smoke	
  daily	
                 	
           #	
  of	
  exercise	
  sessions	
  in	
  a	
  week	
                 	
  
                                            	
  
         #	
  of	
  steroid	
  type	
  drugs	
  used	
  in	
  the	
            	
              #	
  of	
  alcoholic	
  drinks	
  in	
  a	
  day	
                	
  
                                     past	
  year	
  
       #	
  of	
  amalgams	
  (silver)	
  fillings	
  in	
  your	
             	
               #	
  of	
  caffeine	
  products	
  daily	
                       	
  
                                      mouth	
  
          #	
  of	
  street	
  drugs	
  used	
  each	
  month	
                	
            #	
  of	
  toxic	
  exposures	
  (radiation,	
                      	
  
                                            	
                                                      chemicals,	
  insecticides)	
  
                         #	
  of	
  known	
  allergies	
                       	
            #	
  of	
  major	
  injuries	
  in	
  your	
  life	
                	
  
                                            	
  
           #	
  of	
  unresolved	
  emotional	
  factors	
                     	
           #	
  of	
  major	
  infections	
  in	
  your	
  life	
               	
  
                (anger,	
  depression,	
  anxiety…)	
  

         I	
  am	
  responsible	
  for	
  my	
  body	
  1-­‐10	
               	
                #	
  of	
  glasses	
  of	
  water	
  daily	
                    	
  
                                   	
  
                Amount	
  of	
  fat	
  in	
  diet	
  1-­‐10	
                  	
               #	
  of	
  pounds	
  overweight	
  or	
                          	
  
                                   	
                                                           underweight	
  (if	
  applicable)	
  
Client Advisement & Disclaimer Form


I understand that the attending practitioner is not an allopathic doctor (MD), but is a Certified
Biofeedback Specialist and a Licensed Quantum Healer. He is able to identify energetic
imbalances which may represent dis-ease in the body but cannot be referred to as a diagnosis.
All physical issues have energetic components that relate to some form of stress. Therefore, all
stress related issues will be managed with stress reduction and relaxation techniques, pain
management techniques, and methods to help the client improve the quality of life including
detoxification of environmental stressors and enhancement of overall performance.

I understand that the attending practitioner does not provide services that could be defined as
attempting to diagnose, treat, prevent, cure or attempt to cure any medical, emotional, mental or
psychological disease, disorder or condition as defined by allopathic medicine but identifies all
issues as relating to consciousness.

I understand that the attending practitioner does not offer allopathic drugs, surgery, chemical
stimulants or any other conventional treatments, or perform any act that would constitute the
practice of medicine for which a license is required. What is allowed is bringing the client to
awareness, and coaching the client to take responsibility for his/ her own health and initiate self-
healing activities.

I have solicited the attending practitioner’s services in good faith, exercising my free will and
following the dictates of my own conscience which allows me to select what I understand is
most beneficial to my health.

I am fully aware and release the practitioner to do acu-meridian testing, biofeedback testing,
wellness consultation and other stress reduction protocols.

By signing below I acknowledge that I have read and understand all parts of this waiver, that I
have had opportunity to ask any questions with regard to the described procedures, and that I
hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on
this and any subsequent visit solely on my own behalf.




Date (mm/day/year) ______/______/_______


Client Name (Printed)_____________________________________________


Client Name (Signed)______________________________________________
                                Code of Ethics


As a Certified Stress Reduction Practitioner and Licensed Quantum Healer, I will:

   1. Maintain professional competence by keeping informed of the latest
       developments in clinical practice and relevant research.
   2. Accurately advertise credential and educational background.
   3. Only make claims supported by published scientific evidence when disseminating
       information relevant to biofeedback.
   4. Take all reasonable precautions to avoid harm to clients, always demonstrating a
       concern for the rights, safety, health, welfare, culture and dignity of clients.
   5. Provide services without discrimination on the basis of race, creed, age, gender,
       sexual preference, national origin, mental, emotional and/or physical disability,
       disease, and financial status, social or religious affiliation.
   6. Respect the rights of clients to refuse or discontinue services.
   7. Maintain professional, goal-related relationships with clients and avoid personal
       relationships with clients, other professionals and friends which could interfere
       with professional judgment.
   8. Refuse services to prospective clients for whom it is judged biofeedback would be
       ineffective or inappropriate.
   9. Except as otherwise required by law, protect the confidential nature of
       information gained from clinical practice.
   10. Consult with experienced service providers when additional knowledge or
       expertise is required, and refer clients to appropriate service providers when
       necessary.



   Date (mm/day/year) _____/______/________

   Client Name (Print) ___________________________________________

   Client Name (Signature) ____________________________________________

				
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