Shamanic Journey Intake Form

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Name
First Name
Last Name
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Email
example@example.com
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Phone Number
Area Code
Phone Number
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Where do you reside?City, State/Country
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How did you find out about Wholistic Vitality?If someone referred you please write their full name below.
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What is your preferred availability? Keep in mind Shamanic Journeys may last up to several hours while a Shamanic Shadows Healing or Sacred Ceremonies may be more time comprehensive for the thorough approach to covering a lot of ground within one session which for some can be up to 6 hours. Nicolle will try to accommodate your session, including options for evening availability.
What is your availability?
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Which Service are you interested in for this inquiry:
Shamanic Shadows Healing
Shamanic Journey
Sacred Ceremony
Intuitive Astrology Reading upgrade
Photon Sound Beam Machine upgrade
UniverSoul Alchemy
Reiki Ch'i
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Astrological Birth ChartYour astrological Birth Chart is like the blueprint to you which is as unique to you as your own fingerprint...since it is determined by the exact moment of your birth, in how the planetary alignments were configured at that moment in time. Which the art and science of astrology is the ability to interpret the themes represented in the Cosmic archetypes in unique arrangements making up your own unique birth chart. There is much you can delineate from looking at a chart...as it does paint a picture of the personality lens that you perceive, receive and create reality through; as well as compatibility, and predictive astrology. It is especially complimentary to your shamanic journey to understand the many layers of yourself through self awareness, in why you are uniquely the way you are....but what can be learned can also help explore healing in your Shamanic Journey based on innate attributes represented in your chart, alongside the intentions you set up to be explored while in journey. If you are interested in upgrading your journey to include an astrological reading, that may also include intuitive insight and manifesting mentoring within your astrological blueprint...that can be further explored in journey...then please fill out the details below. (Keep in mind this is a $75 upgrade although normally $100 as a standalone service).
What is your Date of Birth and Year (--/--/----)
What is the exact time of your birth to the minute for accuracy AM/PM? (Can usually be found on your birth certificate or perhaps your mother might recall)
What City and State/Country were you born?
Would you like to add the upgrade of the Intuitive Astrological Reading to your booked session? (YES/NO)
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How would you describe your Spiritual or Religious beliefs?
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Have you experienced death or loss close to you that you feel you would like closure or healing with?If your answer is yes, please write down the name of the person/s, your relationship to them, how they deceased, and how that has affected you since? Also please mention if given the opportunity to connect to the soul of any of the mentioned passed on loved ones while in journey, would you welcome this?
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If possible, are you interested in connecting to Sentient Beings or Higher Dimensional Consciousness?Such as Higher Guides, Angels, Guardians, Passed on Loved Ones, SOURCE/GOD/CREATOR, Ancestors, Elders, Star People, Ascended Masters (ex. Jesus, Buddha, Lao Tzu, etc), Galactic Federation, etc.
YESNO
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If you had the opportunity to get any questions answered or guidance from a Higher Perspective, what would you want to know?List any questions you'd like answered in order of importance to you, this may reflect personal questions or questions pertaining to humanity or our planet, or beyond...
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Are you interested in doing Shadow Work?Depending on your interest in diving deep into healing past traumas, we may take the direction of a Shamanic Shadows Healing journey which is a very comprehensive dive into attempting to heal and integrate original timelines where specific traumas took place for you. Our inner "Shadows" if you will, can be considered the unhealed aspects of self, that may have caused fragmentation or dissociation in ones consciousness....this may be where your pain, anxiety, depression or fear originate from or reside within. So even though we often will try to cope with, by avoiding, numbing, escaping, bypassing, rejecting etc... these aspects within us, which often result in sabotaging ones own happiness or wellbeing in the process of, because these aspects much like a shadow, will follow you until resolved. With honest self-reflection, you may recognize patterns in life or your reality, your relationships, or within yourself that are a byproduct of these "Shadows" or wounded aspects of SELF. If you are interested in diving into your Shadow Work, please detail below any relevant traumas that stand out to you that you are aware of. This may include experienced abuse (if comfortable to share, please reference the age you were when these occured, and the extent of the abuse such as physical, emotional, psychological, sexual or other. Reference how you believe this has impacted you in life or any noticeable patterns that may not be serving you?); other examples may include experiencing death or loss; Injuries; Illness; accidents; bullying; perhaps it may be that you felt unloved, unwanted, neglected or rejected in your upbringing; major life changes such as divorce, abortion, miscarriage, or other unexpected or unwanted changes?? etc.
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What are your intentions for your journey if anything were possible to explore, address, heal, reveal, or enlighten?It is important to reflect upon your intentions, as they do help create the "road map" if you will as to what may be awaiting you in your shamanic journey. The more clarity of thought you put into this, will reflect in the profundity of your own unique experienced journey. Intentions may primarily reflect the questions you were seeking answers to in the form of guidance, they may be wanting to address your shadow work; Inner child healing; Past life karmic healing; knowing ones purpose; developing ones own Intuitive abilities; Connecting to your loved ones or Guides; Inter-dimensionally traveling; Cutting cords; Seeking assistance with attachments or malevolent entities; Connecting to your Higher Self or Future Self; feeling ONE with ALL; Feeling Peace or Love; etc. These are some possible examples, but anything is possible within journey based on what you are seeking, your intentions and what you are most receptive or ready for. Try to arrange your intentions in order of your priority.
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How would you describe your current relationship to SELF and/or your awareness of your Inner Child?This is a chance to check in with yourself. How in tune do you feel you are with your emotions, your wants and needs? What kind of thoughts, words, or actions do you direct to yourself....meaning are they self-serving, do you self-sacrifice, self-loathe or self-deprecate? Do you consciously or unconsciously withhold from yourself...do you punish yourself...do you ignore your inner voice or emotions? Do you do whatever you can to not feel what your feeling by indulging in coping methods that are destructive to your wellbeing...such as binge drinking or eating; taking drugs or pharmaceuticals; losing yourself in TV or other addictions such as pornography; etc? OR alternatively, you have done much healing and work on your relationship to SELF already, and you feel this is pretty healthy for you? Please reference how you therefore meet your own needs and wants; how you maintain balance and wellbeing; what are your current practices that nurtures YOU?
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Again check in with yourself with your emotions?How are you feeling? Deep down? There may be many layers to this...ask yourself what emotions come up for you when you ask this? What emotions or states of being, is persistent or most often experienced that you feel may be holding you back? And see if you can identify why those feelings come up for you? What triggers them? Where do they originate? How long have you been feeling those ways?
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Do you have any unresolved feelings towards any of your relationships in your life both past and present?Type the name of the person, their relationship to you, and what has occurred within that dynamic to cause the current unresolved feelings that may still be afflicting you? List all relationships that apply, especially if it pertains to your intentions for healing.
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Do you have any health concerns, impairments, conditions, illness, pain, symptoms, diagnosis etc?Please detail all that applies:
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What fears or worries do you think are playing a big role in your life?Try to identify and describe what these are for you and how they play a role in limiting you?
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Are you or have you ever felt suicidal?Please detail if this is your current feelings and whether or not you have attempted this in your life?
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Are you currently taking any anti-depressants medications?If so, how long have you been on these medications.
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Please list any medications you are currently taking:Please note what reasons you are taking these medications
Medications and use
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Do you feel you have any unhealthy addictions, reliance or attachments to any substances or coping mechanisms?Please be honest with yourself as you reflect on this and detail what you believe what these are for you:
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Have you ever experienced working with any Plant or Indigenous medicines or Psychedelics or entheogens?Examples would be Cannabis, CBD, Psilocybin, Ayahuasca, Kambo; Rapé tobacco snuff; Peyote; San Pedro Bufo etc. Please detail what you have experience with if so, and if you feel you have benefited from working with any of these medicinals?
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List your experience with any alternative healing modalities or services?
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Is there anything else that has not been asked, that you feel might be relevant in mentioning?
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