New Client Intake Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Referred By Please list any areas where you feel stuck, blocked, or limited (emotionally, physically, spiritually, mentally, or in life). * Please briefly describe any traumas (emotional or physical), health issues, hospitalizations, accidents, allergies, or current medications that you feel comfortable sharing in the context of this work. * Please list the desired results of our initial session together (what needs to happen first). * Please list the desired results of our overall work together (where do you want to end up). * What are your big life intentions? What is most important to you? Have you had a Shamanic Healing before? If so, please describe. Have you had prior exposure to Energy work in general? I use many tools in our work together. Please indicate which ones you are comfortable with me using with you. If you are OK with everything, you can just click 'All'. * Sacred Songs, Rattling, Drumming, Sound Healing Sage, Palo Santo, Sweet Grass Feather Work Agua Florida (Flower Water) Energy Work Reiki Essential Oil or Flower Essence Recommendations Guided Inquiry Reflection and Intuitive Guidance At Home Practice Recommendations Shamanic Journeying Allies, Guides, Angels Akashic Records Emotion Code Crystals All I have read and agree to the Terms of Use * By clicking below you agree to our Terms of Use Yes I understand that I will be participating in a energy healing session. This is not a medical treatment nor is the information provided during the session intended to treat, diagnose, cure, or prescribe. I agree to hold my practitioner(s) harmless for any reactions resulting from this session (or series of sessions). I understand that Energy Practitioners are NOT licensed for massage or medical treatment. I understand that it is always recommended to check with my physician before this or any healing work. Understanding the above, I give my permission for this healing work. Electronic Signature: * First Name Last Name Date * MM DD YYYY Thank you!
