Intake Form

Please fill out the following information as honestly and completely as you can. All information will be held in the strictest of confidence and is intended solely for the purpose of assuring the least difficult and most effective healing path.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Present Occupation

What are the top 3-5 things that you would like to work on that, if changed, would greatly improve the quality of your life (these may be stated as goals).

Have you ever experienced intuitive, energetic, or spiritual healing?

Is there any thing else you would like me to know?

Before Your Session

1. Ground and center yourself and find a space that is free of interruptions. It is best if you stay hydrated throughout the day before our appointment and have a water bottle handy during the session.

2. Bring your willingness to heal.

3. If you must cancel, please give 24 hours notice.

Consent & Release

By filling out the form below, I agree: It is understood the purpose of a Healing Session (including modalities such as intuitive energy healing, reiki, and/or other treatments) used is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. This work is a supplement or addition to whatever treatment you are currently receiving or may seek in the future. I understand my Healer is not a licensed counselor nor a licensed health practitioner/provider/physician. I have not come to my Healer for medical advice, diagnosis, and/or treatment. Where applicable, I have informed my Healer about my state of health and I have transmitted any recommendations and restrictions on the part of my medical doctor or therapist. I agree my Healer shall not be held liable for any claim, demand, or cause of action of any kind resulting from or related to the participation in such Healing session(s). I have sought this spiritual service combined with spiritual counseling of my own free will. Client understands Practitioner’s services are consultative in nature and that decisions made, and actions taken, based on input or advice from the Practitioner, are ultimately the complete responsibility of the Client. Client further understands Practitioner shall have no liability or responsibility for any actions of Client taken (or not taken) in connection therewith. Practitioner makes no guarantees or warranties, expressed or implied, as to results to be achieved, or as to the consequences of any actions taken or not taken by Practitioner. Your information and our Healing Sessions are held in the strictest confidence by your Healer. Your Healer will not share or discuss your information with anyone without your prior consent and agreement.

Cancellation Notice: 24-hour notice is required for cancellation. Please call - do not send an email. Missed sessions or cancelled sessions without 24-hour notice will result in a cancellation fee of half the session cost.

I understand and agree to the above statement and cancellation policy.

Type Full Name *

Date *