PeaceQuest Energetics - Registration
PeaceQuest Energetics - Counseling, Reiki, Energy Psychology


When registration forms, personal information form and an Agreement for Services form are completed in advance, it saves time during our first session.  Please complete these forms:

Registration Form (required for all seeking services including classes/workshops):
I am seeking services for
My child
Child's name
I am interested in:
Cuantic System
Eden Energy Medicine
Energy Psychology Circle
Energy Psychology (EFT or WHEE)
Reiki or intuitive healing
Personal Supportive Counseling
Not sure
Reason for seeking service:
I will attend as follows:
In person
By telephone
Via videoconference
Please make a time/date request and I will get back to you soon.
Personal Information Form (required for people seeking individual services or sessions.  Not required to attend a class or workshop):

Please enter as much information as you are able to share.  If the client is your child, please answer the questions as though s/he were filling it out.  Please take care with the form; I review them very carefully before our first session, and it really helps to focus the sessions so you get the most out of them.  Also, it reduces the time we spend before getting down to the work of the session.                                          
Please state next of kin and contact information for them:
Please let me know if you are under the care of a professional:
Counselor / Therapist
Physician /Therapist / Counselor / Other's name and phone number. (They will not be contacted without your permission except in a dire emergency.) Eden Energy Medicine (and other balancing we do) does NOT replace treatment by a physician or therapist. Getting energies in balance can support your treatment goals with whatever you are doing to help yourself.
Please indicate if you have a diagnosed condition:
Acute medical condition.
Chronic medical condition
Psychological condition
Please state the diagnosis or diagnoses (if applicable):
Please list any medications or supplements you are taking. While I am not qualified to make recommendations about medications or supplements, it helps to know what you are taking and we can strengthen your system to tolerate them better if there are side effects!
Please let me know if you have experienced any of the following:
Serious injury or physical trauma
Traumatic loss
Physical abuse
Emotional abuse
Sexual abuse
Serious medical condition
Chronic medical condition
Please say anything you want to about these:
Please let me know if you have in the past had treatment around issues arising from abuse:
Therapy / Counseling
Inpatient treatment
Energy Healing
In Eden Energy Medicine we don't treat symptoms directly, but symptoms are clues to what is going on in the body energetically. We "follow the energy" and bring balance, which may also result in a reduction of symptoms. Please let me know if you are experiencing physical pain or other issues in the following areas:
Feet, ankles, knees, legs, hips or sacrum
Lower abdominal area (ovaries, colon, uterus)
Upper abdomen (stomach, small intestine, pancreas)
Chest (heart, lungs, thymus)
Lower Back
Upper back
Head, Ears, Eyes
Arms, hands
Please say more about what is going on with you physically:
Please say more about what you would like to get out of coming to a group or sessions:

Agreement for Services:

Please print and sign this form and bring it with you to your first session or scan it in and email it to me (

Thank you


Any questions? Contact me!