*First Name:

*Last Name:

E-mail Address:

Re-enter E-mail Address:

Daytime Phone Number: Enter phone numbers as follows: 8005551234

Evening Phone Number: Enter phone numbers as follows: 8005551234

Gender:
Male
Female

What is the main issue(s) you would like to address?

What is your desired outcome of your HCE™ Healing Session?

Relationship Status:
Single
Married
Committed Relationship
Widowed

Sexual Preference:
Heterosexual
Homosexual
Bisexual

Do you have children?
Yes
No

Have you ever experienced sexual violence (rape, incest, spousal abuse, other)?
Yes
No

Though this may be sensitive, please do your best to describe.

Have you ever carried out sexual violence upon another person?
Yes
No

If so, what?

Are you currently sexually active?
Yes
No

Are you happy with your level of sexual activity?
Yes
No

Is pornography part of your sex life?
Never
Occasionally
Frequently
Always

Do you currently use drugs and/or alcohol on a regular basis?
Yes
No

Drugs, which ones and how often?

Alcohol, how often?

Please describe any health challenges, disease or conditions:

Physical?

Mental?

Emotional?

Weight:
Under weight
Average weight
Over weight

Is there anything else that you feel I should know about you that would be helpful for your session?

Please check which days would be best for scheduling your HCE™ Healing Session:
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

Times:
Morning
Afternoon
Evening

HCE™ Client Agreement

As an HCE™ Client, I understand that HCE™ is an energetic healing process. It is not a form of psychological or medical therapy. As a voluntary participant in this process, I agree to take full responsibility for my physical, emotional and mental health and will consult with my licensed medical practitioner should the need arise. I acknowledge that an energetic healing process can involve energy shifts and releases that may, on occasion, cause symptoms that are uncomfortable or disruptive. In proceeding with this treatment, I agree to assume the risk of any such symptoms and agree that I will not to hold Devi and/or Surrender to Love responsible for any such symptoms experienced during or after my participation in HCE™.

I have read, understand and agree to the HCE™ Client Agreement.