Intake Form — wonderFULL Wellness

Intake Form (New Client)

Welcome and thank you for booking your 1st WHOLE Heart Healing Session!

Please complete at least 48 hours prior to your session.

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Have you had energy work in the past? If so, please describe.

Please list any areas in your life that you feel stuck, blocked or limited (emotionally, physically, spiritually or mentally)

Briefly describe any traumas (emotional or physical) health issues, hospitalizations, or accidents.

List any allergies or current medication.

Please list the desired results of our initial session together (what needs to happen first).

Is there anything else that you feel is important for me to know for our time together?

I understand that I will be participating in a energetic 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 practioner harmless for any reaction resulting from this session (or series of sessions). I understand that Practioners are NOT licensed for message 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 hearling work. By accepting this acts as your electronic signature.

Decline