SRT Clearing Request Form

SRT Full Clearing Intake Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
Gender*
(Sex assigned at birth)
Time Zone*
Home Address (for clearing purposes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
The following questions are all optional and some may not apply to your specific situation. All of this is for the most thorough clearing possible and is kept strictly confidential.
Work Address (if different - to clear your workplace)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pets (Name and type of animal)
Present Challenges (major issues, current blocks, persistent problems, limiting beliefs, etc)
Health Problems (phobias, allergies, persistent or recurring physical difficulties, relevant surgeries or illnesses, addictions, chronic pain or other issues)
Relationship "Stuff" (relationship challenges with parents, siblings, children, significant other, coworkers, bosses, friends (etc) or patterns of difficulty in relationships)
Other Relevant Challenges or Concerns (unresolved trauma, stuck or outdated emotional patterns, blocks or resistance to healing and abundance, stagnant creativity life force, etc)
The above information is accurate and true to the best of my knowledge. Spiritual Response Therapy is energetic and spiritual in nature and therefore I understand that this clearing is conducted in good faith with the intention for the greatest good which may not be immediately visible or in a recognizable form; results and/or specific outcome is not guaranteed. I understand that the practitioner is simply a facilitator and does not diagnose disease, prescribe medications, or guarantee results. I further understand that any service offered by Panacea/Arrian Walter is not a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical, mental, or emotional changes that occur with my health. I agree to hold harmless Arrian Walter for any results of any SRT clearing/session and I agree to accept total responsibility for my own physical and emotional well-being.*
Should be Empty:

SRT Full Clearing Intake Form