New Client Intake Studio

Healing to Wholeness
Healing Session Intake

Thank you for trusting me in helping you to create greater health, well-being and empowerment. The personal information you are providing me with is important to me and will be held in strict confidence. I look forward to working together on your healing journey. With gratitude, Dina 🌷
Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
What is your age and birthdate?
What are your relationships to the people living in your household? Ages?
Are you employed? If so, what do you do?
What are you passionate about?
How often do you engage in self-care practices? What are they?
Please list any healthcare professionals you are seeing:
Please list any herbs/supplements/medications you are taking:
What are your current challenges to creating health and well-being?
What do you wish to achieve in our work together?
What is a dream that you have and would love to be able to bring to reality?--your innermost desire--especially if it's something that feels impossible!
Please give details of any of the above or anything else you would like to share:
Everything shared by you will be held in strict confidence.

The intention of Dina Saalisi Healing Arts is to provide you with guidance and support for healing the body, mind, spirit and soul.

Dina Saalisi Healing Arts is not a licensed physician or psychotherpist and makes no claims of medical treatment or cure.

Dina Saalisi Healing Arts does not diagnose, prescribe medication, or recommend that any person change or discontinue medication prescribed by a licensed practitioner.

Dina Saalisi is certified as: National Board Health and Wellness Coach (NBHWC); Bach Foundation Registered Practitioner (BFRP); Board Certified Hypnotherapist (ABH-CH) The healing modalities used in each session are a combination of these therapies, based on a client's specific needs.

By using Dina Saalisi Healing Arts, you acknowledge that you understand and agree to the disclosures stated above and that you take full responsibility for your own healing, health, decisions and actions.
By typing your name, you agree to the disclosure of services provided by Dina Saalisi Healing Arts. *
Once you submit this form, you will be directed to the calendar to choose the date and time of your healing session, and then to PayPal, to secure your appointment. Cancellations or changes must be made at least 24-hours in advance to receive a refund.
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Healing to Wholeness

Healing Session Intake