Client intake form
The information you share will gently guide me to understand your needs more deeply and help us uncover the root cause with greater clarity. Please take your time and fill out the form as honestly and fully as you can. Everything you share will be held with deep respect and complete confidentiality.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Treatment Required
Reiki 60mins
Lightcodes healing 90mins
Ceremonial smudging 45mins
Cord cutting 30mins
Distance Reiki 60mins
Distance Lightcodes 90mins
Psychic readings 30mins
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Have you have any Energetic healing done before?
*
Yes
No
Yes - something else not listed
Are you currently attending a GP/complimentary therapist for any condition/treatment?
Yes
No
Current Medication (incl vitamins):
*
How did you hear about me?
*
Website / Online Search
Instagram
Facebook
Referral
Other
If Referral, please list name
What is the objective of your visit (eg: relaxation, specific condition / pain)?
*
Your General Health
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance (eg PCOS / irregular cycle)
Cancer
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Sinusitis
Back Complaints
Skin conditions
Insomnia
Covid-19
Reocurring infections
Tinnitus
Vertigo
Perforated Ear Drum
Ear Aches
Snore
None
Other
If you checked yes to any of these please provide further information. If not, mark N/A
*
Stress Levels at Home
*
High
Medium
Low
Stress Levels at Work
*
High
Medium
Low
n/a
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
*
Yes*
No
*If Yes, please give details:
FEMALE CLIENTS ONLY: Are you / could you be pregnant
*
Yes
No
N/A
Are you a smoker?
*
Yes
No
Do you drink alcohol and/or take any illicit substances
*
Yes*
No
*If yes please give details: (last used, how often)
Are there any other information you would like to make your therapist aware of? If yes, please give details:
Reservation & Cancellation PolicyA 50% deposit is required to secure your appointment. This deposit is non-refundable but can be transferred if you need to reschedule. I understand that unexpected things can happen, so I simply ask that you give as much notice as possible if you need to change your booking.
*
I understand the reservation and cancellation policies at Portals byPixie
Do you consent to any photos being taken during this session (if appropriate and permitted), and are you happy for me to share these images for marketing purposes (such as on my website or social media)? Please let me know your preference — your comfort and privacy are my priority.
*
By checking this box you concent
By checking this box you do not concent
CLIENT DECLARATION: I confirm that the information I’ve shared is true to the best of my knowledge, and I feel safe and comfortable to receive an energetic healing session with Jessica Unali. I understand that this treatment works alongside and supports Western medical care, but it doesn’t completely replace it. If I have any concerns about my health, I know it’s important to also speak with my GP. My well-being is important, and I take responsibility for how I care for myself during and after the session. If at any point I feel uneasy or would like anything adjusted, I will let Jessica know — as my comfort is a priority. I choose to receive this healing with trust, openness, and a willing heart.
*
By checking this box I understand and accept this statement
I, Jessica Unali, trading as Portals by Pixie, may occasionally contact clients after a session to check in on their well-being. I also send booking confirmations and appointment reminders via email or SMS. I might share events or news via email—you’re welcome to unsubscribe from these marketing messages at any time.Please confirm that you give your permission for Portals by Pixie to:
*
Contact you about appointment and relevant follow up.
Signature
*
Thank you for taking the time to complete this form - I look forward to seeing you soon.
Jess.
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