1:1 Energy Healing Intake Form

Please fill out the following intake form. This allows me to get to know you better, so I can provide support that meets your needs. Thank you!

Name (First and Last)*

Preferred Pronouns

Mailing Address

Email*

Mobile phone*

Emergency Contact*

Do you have any medical conditions?

Any health concerns or symptoms?

Have you experienced energy work before? If so, is there anything you’d like to share about your experience?

What would you like to receive from the session? Do you have an intention you’d like to share?

Do you have any particular areas of concern?

Are you sensitive to any fragrances, incense, sage or other?

Do you have any questions or concerns?

How did you hear about us?