Intake form for Holistic Practitioners

✨Heal with Tiff✨

Let’s Heal Together!
The following information will be used to help me get a brief understanding of where you are and what you need assistance with on your healing journey, prior to our 15 minute call. Please answer briefly, truthfully to the best of your knowledge. All information provided is private and confidential.

*Disclaimer*
Please schedule an available time for our call that is convenient for you.

Please be advised that you can only book once under the same email. So be sure to schedule a time that you’re confident you’ll be able to keep. This allows space for those who truly desire help on their healing journey. Not showing up for your call would result in being added to the ‘No service’ list. Thank you for understanding.
Name*

First NameLast Name
What area are you located?

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Área CodePhone Number
E-mail*
Date of Birth/Zodiac*

MonthDay
What do you feel you need help with on your journey to self?*
Would you consider yourself to be religious, spiritual, a combination of both or you’re just not sure? This helps me to meet you where you are. *
What are your current main concerns? (i.e: medical/mental/emotional /spiritual)*
Do you have any allergies or any limitations that’ll prevent you from stretching, grounding (in nature), or any breathing issues?*
When circumstances arise, briefly explain what you do to get through?*
Are you currently seeing a therapist?*
Have you had a spiritual awakening? (If aware)*
How would you like to feel after our session?*
What is your favorite color? (if any)*
CriticisedOverwhelmedApprehensiveUncertaintyAgitatedParanoidIntolerantGuiltyOverworkedAggravatedNumbDepressedRejectedEasily IrritatedIn a state on psychosisHelplessAnxiousHopelessUneasySadDepressedGrievingAbusedFearfulUnable to GrieveDistressImpatientAngryWorriedOutragedSleeplessNervousRestlessIntimidatedNONE
DigestionRespiratoryCardiovascularNervous SystemMuscle / JointsLymphatic SystemEndocrine System
Please provide further details in relation to any areas you chose above or ANYTHING else you feel I should be aware of.
Yes! Would love toNo, but thanks
How did you hear about me?
If other, please specify below
If other please specify, how did you hear about me?
Yes! I’m ready!Nervous, but ready!
For our FREE 15 min call, what date/time works best for you?
Should be Empty:

✨Heal with Tiff✨