LeftWink LightWork Client Intake Form

Client Intake Form All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent, with the exception of danger/threat of danger posed to client or someone else. You must disclose information with full honesty.
Full Legal Name*

First NameMiddle InitialLast Name
Your Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*
Format: (000) 000-0000.
Your Birth Date*

MonthDayYear
Your E-mail*
example@example.com
Emergency Contact Name & Relation*
Emergency Contact Phone Number*
Format: (000) 000-0000.
Your Occupation
How did you find out about the services of LeftWink LightWork?
What are your intentions/goals for this session? *
ReikiHypnoReikiHypnotherapyNLP CoachingLife of Success CoachingTarot/Oracle ReadingEFT Emotional Freedom TechniqueInner Child HealingNone of the Above
If yes to any of the above, when was your last session?
Not at allSomewhatVery
0-25%26-50%51-75%76-100%
List Areas of Discomfort or Pain either Physical or Emotional:*
Have you ever been in an accident or had surgery, if so when and what type?*
What challenges are you currently experiencing in life and what steps have you taken to overcome these challenges?*
List any exercises or stress reduction activities you partake in such as hobbies:*
Do you have any allergies or sensitivities to topicals or scents?
Next Section: Health History & Diagnosed Conditions. Please answer with full disclosure. All information is private. Click Next to begin.
Are you currently under regular care of a physician/specialist for a diagnosed condition? *
Please list any prescribed or over-the-counter medications you are taking*
If you are pregnant, how far along are you?
Do you have any diagnosed or undiagnosed Anxiety, Depression or PTSD that I should be aware of? If so, please specify:
Please Read the Consent and Sign Here:*

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Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Hover over or click on box to read Consent.
Covid Protocols Agreement, Please sign Here:*

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Hover over or click on box to read Covid Protocols
Should be Empty: