Emotion & Body Code Intake Form

Section 1 — What to expect

The Emotion Code and Body Code work by identifying and releasing trapped emotions and energetic imbalances stored in the body. Sessions are done remotely — your practitioner connects to your subconscious through proxy and communicates with it through muscle testing.

In approximately 20% of sessions, releasing emotions may result in a "processing" period where echoes of what was released manifest as temporary physical or emotional discomfort. This is a normal part of regaining energetic balance and typically passes within 1–3 days. Signs of processing can include headaches, flu-like symptoms without fever, crying, agitation, vivid dreams, or changes in sleep and energy levels.

These methods are not a substitute for medical care and are not intended as medical advice. No claims are made as to healing or recovery from any illness. If you experience any physical or emotional reactions that seem extreme or persist, please seek appropriate medical care.

I understand what Emotion Code and Body Code sessions involve, including the possibility of a processing period, and I understand these methods are not a substitute for medical care.

Section 2 — Informed consent

I understand that releasing trapped emotions or correcting energetic imbalances is not a substitute for medical care and should not be used for medical diagnosis or treatment.
I understand these methods are not a replacement for professional psychotherapeutic or counselling sessions in the treatment of mental health issues or disorders.
I understand my practitioner makes no claims as to healing or recovery from any illness, and that no guarantee is made towards validity. The use of any information I receive is at my own risk.
I understand that if I have health concerns, I am recommended to seek advice from an appropriate medical practitioner before making any decisions about my health.
I understand that these sessions are confidential and that any personal information will be kept private.
I understand I am encouraged to be self-informed about this work by visiting Dr. Bradley Nelson's website at discoverhealing.com or reading his book The Emotion Code.

I have read and understood the above and I fully consent to participating in Emotion Code and/or Body Code sessions with my practitioner.

Your information

Full name *

Date of birth *

Phone *

Email *

Primary reason for your visit *

Anything else you'd like your practitioner to know

Electronic signature

By typing your full name below, you are signing this document electronically. You confirm that you have read all sections of this form, that the information provided is accurate and complete to the best of your knowledge, and that you fully consent to participating in Emotion Code and/or Body Code sessions with your practitioner.

Type your full name to sign *

Date signed *

By checking here, I consent to the use of my electronic signature in lieu of an original signature on paper. I confirm all information provided is accurate and complete to the best of my knowledge.

Your submission is sent securely to your practitioner.
Questions? Text (443) 254-6762.

Intake form received 🌿

Thank you for completing your intake form. Jane will review it before your session.
Questions? Text (443) 254-6762.

Section 1 — What to expect

Section 2 — Informed consent

Section 3 — Health intake

Your information

Electronic signature

Intake form received 🌿