Divine Bliss Living Intake Form

Divine Bliss Living

Intake Form
First of all, we just want to take the time to congratulate you for taking the first step to your Divine healing! This is a huge step! We know it’s hard to invest in ourselves, we tend to put every one and thing else above our own desires and needs. So, good for you for taking this huge step to coming home to remember your inner divinity!

Please take your time in completing this form so that we can better serve you.

Please note that all information (written or obtained during your session) is confidential.
Full Name*

First NameLast Name
Are you 18+?*

YesNo
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
What services are you interested in? (Please Select) *Currently not facilitating in person Ceremonies*
Health History Please Check All That Apply Past/Current (notate any current issues in notes below)*

Thyroid DiseaseLow Blood PressureAllergiesAnxiety DisordersFood SensitivitiesHeart ProblemsCirculatory ProblemsDepressionAddictionHypoglycemiaCancer / TumorHeadaches/MigrainesJoint/Muscle PainAsthmaDiabetesEating DisorderClaustrophobiaMeningitisEpilepsyPhysical DisabilityAneurysmChronic PainFibromyalgiaHead InjuryNeurological DiseaseInfectious DiseaseGynaecological ConditionNONEOther
In detail, please explain any medical conditions selected. If there is any additional medical information that you feel we need to be aware of please explain. If none, type none. *
Most Recent (within 6 weeks) & Current Prescriptions & Dosage*
How would you describe your spiritual beliefs / practices, if any?
Check all that apply

I have experienced crystal healing beforeI have experienced a Reiki session beforeI have had an energy balancing session beforeI know about chakrasI have used holistic remedies beforeI have a spiritual path that I am consciously followI have experienced traumaI have difficulty adjusting to new situations and or peopleI am generally uncomfortable with touchI am generally uncomfortable expressing myselfI love myselfI accept myselfI am comfortable expressing myselfI feel like I belongI have experience with Sacred Plant Medicine
When are you interested in participating in one or more of our Services? (Please Select)
Have you worked with Sacred Plant Medicine before?*

YesNo
Which medicine(s)? When?
Are you interested in our virtual psilocybin micro dosing and/or spiritual mentorship container "Mystical Micro Magick"

YesNo
If you have not done so, please take some time to reflect deeply on this question. It is very important for us (and you) to clarify what you hope to achieve by working together. What is your intention?
Have you experienced what you would regard as a traumatic incident in your past that you would like us to know about? If yes, please provide any additional information below that you feel may be helpful for us in supporting you..
Is there anything else you want to share?
Would you like to be added to our newsletter?*

YesNo
Client Name*
Emergency Contact Name*
Emergency Contact Phone Number*
Signature of Client or his/her personal representative*

Clear
Date*

MonthDayYear
Date
This form has been created and will be confirmed by Spirit of Truth Native American Church (the authorized representative of this office or practice)
Should be Empty: