Intake and Consent form : Online Health Center IHA
Welcome to Online Health Center: International Healers Association : Branches - North America and South Asia) Services offered online Worldwide. PLEASE NOTE: All questions are answered only via email ( email Consultations), Phone calls are a part of paid therapy sessions and not for setting up appointment date or any other discussions. We bring global healers together into our Virtual Clinic. Blessings !
First Name
Last Name
Email
Phone Number
Address
Age
Relationship Status
Single
Married
Common Law
Separated
Divorced
Any Other
If married, Date of Marriage? dd/mm/yyyy
Whom to contact in case of Emergency: Their Full Name, Relationship to You, Home phone, Cell Phone, Email, & Address
Educational Qualification/s
Occupation / Job
How did you know about this clinic ?
Business Website
Referred by a client of this clinic
Referred by another healthcare professional
Google Search
Other
Your Skype ID
Country code and Whatsapp Phone Number
Reason for Seeking clinic Services ?
If you have received therapy before: Which therapy and for what issues?
Fees as per DURATION, NO extra TAX is charged
30 min - 80 USD / 100 CAD Worldwide (35 USD if in South Asia)
45 min - 120 USD / 150 CAD Worldwide (45 USD if in South Asia)
If you are in CANADA: Your Insurance provider covers you for
Registered Psychotherapist (80 USD/100 CAD -30 min, 120 USD/150 CAD - 45 min.)
Registered Psychologist (200 CAD - 45 min)
Not Covered by any Insurance (70 USD, 70 CAD for 30 min, 120 CAD for 45 min)
You have approached me for ?
Psychotherapy , CBT, REBT, Counseling
Hypnotherapy , Clinical Hypnotherapy
Psychotherapy-Hypnotherapy combined : Holistic Approach
Psychotherapy integrated Past Life Regression Therapy
Psychological Therapy Services (in SOUTH ASIA)
Psychotherapy integrated Spiritual Therapy
Psychotherapy integrated Energy Healing ,Akashic & Pranic other Modalities
Psychotherapy integrated Reiki / Chakra Healing
Ancient Home Remedies etc... for Body and Mind issues ($15 USD Via email)
Online Text/Chat Therapy with Appointment(North America -30 CAD -15 min),South Asia (500 INR 15 min)
HART -Receive Direct Answers for Mental and Physical Health issues without therapy($5 USD per que)
Apply for Accreditation of Courses provided as a Facilitator and become a IHA certified member
Certification Courses / Workshops offered : REBT-CBT, Hypnotherapy, Past Life Regression, HART
Virtual Clinic Workdwide Services - Best Professionals Online
For Canada - Annual Coverage amount given by your insurance
For Canada - Name of your insurance provider and Annual Coverage Balance Left.
Your Preference for a Session with Renuka (Note, if no internet, then Direct Phone service is provided in Canada)
Live online VIDEO Session( Requires Wifi / internet)
LIVE TEXT / CHAT (40 CAD - 30 min), RP Insured
Direct PHONE Call Session (Canada) (No Wifi or internet required)
Direct Whatsapp Phone Call session International ( Requires Wifi / internet)
OFFLINE Email Paid Chat ( 30 CAD - 30 min), RP Insured
Provide a brief assessment of Physical Health: (nutrition, handicapping conditions, developmental history, physical capability, medications and dosages
Substance Abuse: (history, treatment attempts, current status, interviewer’s observations, other addictive behaviors)
Client Work Concerns, Check all that apply to you
Need a Career Change
Financial Concerns
Difficulties at work
Problem making Decisions
Overwork / Stress
Colleague Issues
Work Timing
Wanting a Job change
Personality Conflicts
Not Applicable
Concerns about Self and Health
Concerns about medications
Eating Disorder - Binging ,Purging
Anorexia Nervosa
Bulimia
Emotional eating
Junk Food / Non- Nutritional Eating
Difficulty Sleeping
Nightmares
Dizziness
Body Pain
Digestive Issues
Illnesss
Decreased Appetite
Increased Appetite / Over eating
No Self Confidence
Feeling Anger
Dealing with Loss
Trouble Concentrating
Feeling Panicky
No Feeling at all
Feeling easily hurt
Depressed
Anxious
Unhappy
Suicidal Thoughts
Tired all the time
Menopause - Pre / Post
Menstrual Cycle Issues
Not Applicable
Social Relationships
Difficulty making friends
Problem maintaining Relationship
Feeling Lonely
Difficulty Relating to people
Fighting in Personal Relationship
Shy with people
Living Alone
Not Applicable
Family Relations / Spouse concerns
Verbal Fights
Marital Concerns
Victim of Physical Abuse
Victim of Sexual Abuse
Sexual concerns / Sexual Performance
Communication issues
Not Applicable
Family Relations/ Children
Health Concerns
Academic Concerns
Behavioral Issues at home or school
Conflict over child raising
Care giver stress
Traumatic environment
Not Applicable
Goal in Therapy
Develop Assertiveness
Develop Coping Skills
Increase awareness of emotional response
Accept Personal limitations
Achieve realistic Self Expectation
Spiritual work
Not Applicable
Habits / Addiction
Alcohol
Smoking / Nicotine
Tobacco
Hard Drugs
Weed / Marijuana
Sex
Fetish
Watching Porn
Not Applicable
Upload your latest Health Reports / Picture of Medicine you are taking if needed
Select a File
Write a message
Session with Renuka : My Preferred Days and timings
Team IHA : My Preferred choice for an appointment
Between 6 am & 11 am EST (Mon- Fri), 3.30 pm - 8.30 pm IST - IHA Team
Between 9.30 pm to 11 pm EST (Mon- Fri) , 7.00 am - 8.30 am IST - IHA Team
Between 6 am & 11 am EST (Saturdays), 3.30 pm - 8.30 pm IST - IHA Team
Not Applicable
How frequent do you wish to meet for a session ?
Once a week
Twice a month
Thrice a month
Once a month
Need Based , Undecided
I agree to the terms & conditions : I am aware the fees for the session have to be paid atleast two hours before, on the day of the appointment, unpaid fees results in cancellation of the booked appointment, which requires rescheduling.
I will be paying by E-transfer / Interac / Direct Bank transfer to therapyhealingclinic@gmail.com, Credit Card (extra $5 charge as Processing fees), PayPal extra $5 (rensforu@gmail.com)
If Paying by Credit Card , I consent for card details to be on my file with the Clinic
Consent Form for Reading
Know the IHA Team
About HART
Global Fees
Annual Booking for 2025
Yes I have clicked the link above and read the 'Consent Form' of the Clinic and I give my Consent.
Today's Date
Your Signature
*
Clear
Submit :-) - Blessed
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