Violets In Bloom Energy Intake Form

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all rights reserved. 2022
Greetings!

Thank you for stopping here and thanks for being curious about energy work. I love the healing effects of balancing the subtle energy areas of the body, mind and spirirt. Attention to these areas bring about a unique sense of empowerment, reduces fear and increases self love. I invite you to fill out this form and I will be in touch with you soon after. This work is one of my life's passions and I know I am capable of supporting you in it successfully. Thank you again. Sincerely, Ava
Disclaimer

Crystal and Usui Reiki Energy Facilitation and other types of energy meridian work are not to be considered as a substitute for traditional medical treatment.
Client Intake Form
Name (First & Last):
Address:
Phone Number (with Area Code):
Email Address:
example@example.com
Date of Birth:

Month Day Year
Date
Preferred Gender(Please Mark Your Preference)
She/Her
He/His
They/Their
Marital Status (Mark Your Current Status):
Single
Married
Divorced
Widower
Occupation:
Emergency Contact Name (First & Last):
Emergency Contact Phone Number:
Emergency Contact Email Address:
example@example.com
Emergency Contact Relation to Client:
What Attracted You to Energy Healing?
Do you take any prescribed medications?
Yes/No (no need to disclose names or milligrams)
Do you have a history of any of the following:
- Heart Disease
- Diabetes (type 1 and or type 2)
- Chronic pain
- Behavioral disorders
- Therapy/counseling
- Drug abuse
- Cigarette smoking
Yes/ No (please offer explanation of any and all)
Do You Follow Any Spiritual Practice? If so, what?
Have you had any prior experience with energy healing? (please mark the appropriate level)
None
A Little Bit
Lots
If you have worked specifically with crystals in the past, please share a little bit about your overall experience here:
Why would you like to learn/accomplish from your visit?
Please specify any additional or pertinent details:
Please sign and date below to assert that the inforation provided is true to the best of your knowledge By signing below you are consenting that you understand that crystal healing is not meant to replace conventional medicine, but rather to complement and enhance it. You should always consult a medical professional when needed. By signing below, you hereby release the healer from any liability as a result of the services rendered (including intake and follow ups).
Client Signature

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Date

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Date
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COPYRIGHT ©Violets In Bloom

Greetings!

Disclaimer

Client Intake Form