Ruqyah Intake Form

1. Personal Information
Full Name:*
Age:*
Gender:*
Languages Spoken:*
Place of Birth:*
Nationality:*
Phone Number:*
Email:*
Home Address:
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
2. Booking Details
Preferred Session Type:
Preferred Availability (Days/Times):*
3. Presenting Concern
Please provide a detailed description of your primary concern. In your response, include when the issue first began, how it has progressed over time, whether it has improved, worsened or remained the same, and any patterns or triggers you may have noticed. Additionally, explain how this condition is currently affecting your daily life, including areas such as your work, studies, relationships, emotional well-being and ability to focus on acts of worship such as your daily prayers.*
4. Reported Symptoms
Please check any symptoms you are currently experiencing:
5. Religious Practice
How would you describe your consistency in the five daily prayers:
How often do you read the Qur’an:
Do you maintain daily remembrance (morning and evening):
6. Medical Background
Do you have any diagnosed medical or psychological conditions:
Do you have any diagnosed medical or psychological conditions:
Do you have any diagnosed medical or psychological conditions:
Are you currently taking medication:
7. Previous Ruqyah
If yes, please describe what was done and the outcome:*
8. Understanding and Commitment
Do you understand that healing comes from Allah alone:
Are you willing to follow guidance based on the Qur’an and Sunnah:
Are you committed to following the instructions given during treatment:
9. Consent
I confirm that the information I have provided is true to the best of my knowledge. I understand that Ruqyah is performed according to the Qur’an and Sunnah. I believe that all healing comes from Allah alone.
Full Name:*
Date*
MM slash DD slash YYYY

1. Personal Information

2. Booking Details

3. Presenting Concern

4. Reported Symptoms

5. Religious Practice

6. Medical Background

7. Previous Ruqyah

8. Understanding and Commitment

9. Consent