Registration Form for New Clients

Please fill out the following form

It will help me better understand your situation and tailor our work to what your system currently needs. You’re welcome to leave any fields blank if they don’t feel relevant right now.

Please note that I am not a medical doctor or psychologist. Resonance Repatterning, Biofield Testing, LebensTransfer and other healing modalities that I am offering are forms of energy work and not a substitute for medical or psychological treatment.

By submitting this form, you acknowledge that the purpose of each session is to support the release of energetic, emotional, or mental blockages and to activate new inner resources.

You understand that this work does not involve diagnosis or prescription, and that it is not intended to replace professional medical care.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Personal Information

Name (first name and last name)*

Email*

Address*

Mobile number*

Date of Birth (DD.MM.YYYY)*

Current age

Occupation

Single / married / in a relationship

Background and Personal Context

How did you find me?

Are you religious or spiritual?

Do you meditate or practice any form of mindfulness?

Do you currently work with other practitioners, therapists or coaches? If yes, please specify.

Medical and Health Background

Do you have any diagnoses related to psychological or neurological conditions (e.g. psychosis, epilepsy)?

Do you have any chronic illnesses or recurring physical complaints? If yes, since when?

Are you aware of any hereditary or familial illnesses?

Do you currently take any medication or supplements? Please list them.

Have you had any major surgeries, accidents or hospitalizations? If yes, when?

Infections, Immune System and Other

Have you had any serious or recurrent infections (e.g. Lyme disease, Epstein-Barr, COVID, recurrent infections)?

Do you experience frequent inflammation, fatigue, or immune-related issues?

Please list any vaccinations you have received (e.g. childhood vaccinations, tetanus, COVID, travel vaccinations).

Have you ever noticed strong reactions to medications, vaccinations or environmental factors?

Are you aware of any food intolerances or digestive sensitivities?

Emotional and Psychological State

What are your emotional and physical problems?

Since when do you have them, and what happened, when they first appeared?

Which difficult feelings did you have in the recent months?

e.g. sad, powerless, depressed

Do you experience fears, anxieties or phobias?

e.g. sad, powerless, depressed

How would you describe your current energy level?

e.g. sad, powerless, depressed

Stress and Life Areas

In which life areas do you have stress and how much stress (from 1 to 10, 10 being the highest stress factor)

e.g. family, relationships, finances, health, other

How are your family relationships and the quality of your relationships with them?

Are there unresolved conflicts, separations or losses that still affect you?

Goals and Motivation

What are your expectations regarding the work with me?

What have you already tried so far to address your issues?

What would you like to feel or experience after a successful transformation?

How willing are you to change (1-10; 10 being the most willing)?

Consent and Disclaimer

Please confirm with “Yes” that you understand that I am not a doctor or psychologist. Resonance Repatterning, Biofield Testing, Life Transfer, and other healing methods I offer are forms of energy work and are not a substitute for medical or psychological treatment. By submitting this form, you confirm that the purpose of each session is to release energetic, emotional, or mental blockages and activate new inner resources. You understand that this work does not involve diagnosis, medical or psychological treatment, and is not intended to replace professional medical care.*

Place, Date*

Signature*

Please enter your full name; this will serve as your digital signature.