• New Client Intake Form

    Energy Healing & Massage Services
    New Client Intake Form
  • Format: (000) 000-0000.

  • Health and Wellness History

  • Do you have any existing medical conditions or concerns we should be aware of?
  • Are you currently taking any medications?
  • Have you received any form of holistic or energy healing before?

  • Purpose of Visit

  • What brings you to Synergy Harmony and Balance Wellness today?
  • Type of Service desired today?
  • Appointment

  • Understanding Our Services

  • Our practice at Synergy and Balance Wellness is rooted in holistic healing. Some of our services include tantric massage as a form of therapeutic and spiritual wellness. Are you seeking holistic healing and wellness services?
  • It's important to note that our focus is on promoting holistic well-being and spiritual balance, and not on recreational or entertainment. Are you seeking services for recreational or entertainment purposes only?

  • Additional Preferences:

  • Do you have any specific preferences or concerns related to your session?

  • Consent

  • I am seeking services at Synergy Harmony and Balance Wellness for the purposes of holistic healing, spiritual growth, and overall well-being. I understand that the services provided are professional and therapeutic in nature and not intended for recreational or entertainment purposes whatsoever. I will not ask for, and/or cross any boundaries that exceed the limits of the law or my practitioner. Violating this will result in the immediate termination of your session with no refund. 

  • Thank you for taking the time to complete this form. Your well-being is priority, and we look forward to tailoring our service to meet your inique needs.

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