Harmoniyum - Quantum Biofeedback, QXCI, EPFX, SCIO, by Marion White, PhD

What our clients are saying...

Read Their Testimonials

Home | About Marion | Contact

SERVICES

Quantum Biofeedback

Group Programs

Personal Sessions

Practitioner Training

Affiliate Program

RESOURCES

Products

Websites

Healing Modalities

Client Intake Form

Please complete the Client Form at least 24 hours prior to your session

Open Client Form

Receive email notification of the latest news from harmonium.com.

Please enter your email address:

Real-Age Calculator

Your health, lifestyle, and habits have a dramatic affect on your lifespan.

Try the Calculator

CLIENT INTAKE FORM

Please note: I am not a medical doctor. By law, I cannot diagnose, treat, cure or prevent any disease. I am not a licensed psychologist. By law, I cannot diagnose, treat, cure or prevent any psychological disorder or disease. I am a Certified Biofeedback Specialist and I do not diagnose, treat cure, or prevent any disorder or disease. I do not dispense nor recommend any drugs of any kind. I do not treat medical or psychological conditions. - Marion White PhD

Please fill out this form before your first appointment.
Name
Email
Address
City
State
ZIP
Phone (home)
Phone (work/cell)
Birthdate
Time of Birth
Birth Place City/State
No. of Organs Removed All teeth = 1
No. of Prescription Drugs
No. of Cigarettes smoked per day
No. of Steroid Drugs taken
No. of Metal Fillings
No. of Street Drugs taken
No. of Allergies
No. of Unresolved Mental Factors Greed, resentment, anger, etc.
I am responsible for my body 0=no 10=yes
% Fat in Diet (average is 45%)
Personal Stress None=0 Max=10
No. of Sugar products per day
No. of Exercise sessions per week (20 minutes+)
No. of Alcoholic beverages per day
No. of Caffeine products per day
No. of Extreme Toxic Exposures per year (chemo, radiation, etc.)
No. of Major Traumatic Injuries in life Mental, emotional, physical- accidents, etc.
No. of Major Infections
Glasses of Water you drink per day
Pounds you feel overweight
Please indicate any areas of interest for the QX session
Personal History
Referred By

Disclaimer:
For the diagnosis or treatment of any disease please consult a licensed physician.