*Email (to contact you)
*What classification are you coming under (main issue)
Please describe your condition as far as is comfortable for you to share.
How long have you had this issue?
Are you currently undergoing any treatment or therapy for this issue?
What kind of treatment or therapy (briefly)?
Are you open to exploring the Mental, Emotional and Spiritual aspects associated with your condition from a Medical Qigong perspective?
Are you willing to spend some time doing Qigong prescription exercises?
*What would you like to get out of your session?
How did you find out about the clinic?
Is there anything else that you feel it is important for your therapist to know?
* I understand that the person who I will be working with is not a Medical Doctor and does not medically diagnose, treat or prescribe. I understand that this is a Medical Qigong student clinic that I am volunteering for and that information about this session might be shared anonymously as part of the student's learning experience.