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Mon-Sun 09:00-20:15 (by appointment only)
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Intake form

The Portal to
Your Well-Being

Harmonise yourself from within using colours, sounds, vibrations, and energy resonance.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Intake Form

All new clients are asked to complete a detailed history prior to their first visit. This helps determine the best form of treatment. Please fill out the form below before your first appointment.

While most people see results after just one session, it is strongly advised that a minimum of 3-5 sessions be completed. As a general rule, we recommend 3-10 sessions. For chronic conditions or severe diseases, we recommend 10 or more.

Your data is protected! We believe your data is your property and support your right to privacy. Your data is not shared with 3rd parties.

Disclaimer: No part of this site is intended to diagnose, treat, or cure any illness. Nothing on this site is to be construed as medical advice; the authors are not doctors. Please discuss your personal health, including any options or ideas you may read on the internet (on this site or others) with your personal, qualified health practitioner before making changes to your diet or adjusting/discontinuing any medication. We are not responsible for any adverse outcomes associated with using or misconstruing advice or information on this site.

Alternative/non-mainstream modalities or technologies can make no legal claims. However, this doesn’t mean they are not efficient in helping to beat severe health conditions

*First name (required field)

*Surname (required field)

Date of Birth

Height

Weight

Telephone Home

Work

*Mobile (required field)

*Email (required field)

Street and house/flat number

City

Postcode

Emergency Contact

Relation

Phone

Relation status

Spouse/Partner Name:

# of Children

Occupation

Do you enjoy your job?

Yes No

Primary Reason for seeing us:

Have others helped you with the problem:

What are your expectations after the sessions:

Who can we thank for your being here (who referred you):

Check conditions listed below which you have experienced: Use P for over a year ago, C for current

METABOLISM

Weight Gain

Weight Loss

Heigh/Low Blood Pressure

Blood Sugar

Thyroid

DENTAL

Tooth Problems

Root Canals

Amalgam Fillings

Difficulty chewing

TMJ

DIGESTION

Heartburn

Abdominal Pain

Gas/Bloating

Diarrhea

Constipattion

Blood in Stool

History of Ulcers

Colitis

Liver Desease

FEMALE

Pregnant

Problems with periods

Cancer

Breast Tenderness

Breast Implants

Menopausal Symptoms

SKIN

Rash

Eczema

Dry Skin

Acne

Recent Botox

Any recent substance Injection under skin

CHEST

Chest Pain

Palpitations

Cough

Shortness of Breath

Asthma

URINARY

Frequent Urination

Difficulty starting Urination

Urinary Incontinence

STRUCTURAL

Arthritis

Bursitis

Osteoporosis

Foot/Ancle Swelling

Blood Clots/Phlebitis

Varicose Veins

Recent Surgery

Neck Pain/Problems

Back Pain/Problems

Sciatica

EYES/EARS/MOUTH

Headaches

Dizziness

Ringing in Ears

Blurred Vision

Sinus Problems

Difficulty Swallowing

Mouth Sores

NEUROLOGIC

Numbness or Tingling

Weakness

Insomnia

Poor Balance

MALE

Prostate

Cancer

ALLERGIES

Medications

Chemicals

Foods

Plants

IMMUNE

Chronic Fatigue

Fibromyalgia

Yeast Infections

Past Viral Infections

Past Strep or Mono

Epstein-Barr

Lyme

Medications, Herbs, Supplements (list name, dose, and purpose)

We recommend drinking 2.5 - 3.5 liters of water daily starting on the day before your first session and for the days of integration.

Do you expect any difficulty with this?

Yes No

Explain:

How much do you use per week?

Alcohol

Tobacco

Coffee/Tea

Drugs/Marijuana

Injuries/Accidents?

Yes No

When & Describe

Traumatic life events leading to any illness:

Toxic Exposures:

Describe other medical conditions that we should be aware of:

Other:

Areas in body of complaint or tension:

Surgeries with dates (include location of metal plates/rods/screws)

Other

Current Pain Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Stress Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Energy Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Describe any specific medical attention or assistance you will need while visiting our center (you must be able to get into the unit or bring a caregiver to help you).

Will you be bringing a caregiver, nurse or spouse with you?

What brings you joy?

Please check the box of the most emotional draining relationship or relationship in your life:

Is your home environment peaceful or stressful most of the time?

Do you have trouble concentrating, or ‘brain fog’?

Yes No

Do you feel supported?

Yes No

What drives you, inspires you, gives you a sense of purpose:

Please check the emotions that best reflect how you feel most of the time:

Do you adhere to any particular diet?

How many hours of sleep do you get on average?

Do you drink filtered or purified water?

Yes No

Describe your exercise/activity routine:

Are you sensitive to light / loud noise?

Yes No

If Yes, Please explain:

Are you in fear regarding your health?

Regaining well being requires a strong personal commitment. How ready are you to make the lifestyle changes, the diet changes and the attitude changes that may be necessary to good health?

Ready Somewhat Not looking to make changes

I have read the above information and have filled out the form to the best of my knowledge. I understand that the questions on this form are being asked in order to better access my current circumstances and their relationship to my well-being. I further understand that I am voluntarily agreeing to have a relaxation therapy session and that no medical claims or promises of healing have been given.

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Visit Our Blog for Timely Information.

What to Expect →

Our advice & Protocol For Sessions & Our Promises

Advanced Energy Therapy

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Location

Rijksstraatweg 675
2245 CB Wassenaar
Located in Villa Maarheeze: 2nd floor, unit 2.6
Free parking, Wheelchair accessible

PRIVACY / TERMS

CONTACT US

Disclaimer: The statements made or services provided through this website or by the Company are not intended to diagnose, treat, cure or prevent any disease. Testimonials regarding the technology are voluntarily given and do not represent the opinions of the Company. The services provided by the Company are not intended to be a substitute for professional medical advice, diagnosis, or treatment.

MADE WITH ❤︎ BY GL

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Intake form

The Portal to Your Well-Being

Harmonise yourself from within using colours, sounds, vibrations, and energy resonance.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Intake Form

Check conditions listed below which you have experienced: Use P for over a year ago, C for current

Visit our page →

FAQS →

News & Advice →

What to Expect →

Advanced Energy Therapy

Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Location

CONTACT US

The Portal to
Your Well-Being

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.