Intake Form

Client Intake Form
Please fill out this form to help me better understand your needs and provide the most effective healing session for you.
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Occupation
1. Do you have previous experience with Reiki, energy healing, breathwork, manifestation, or mentorship?
If yes, please briefly describe:
2. What intention or desire lead you here today? (e.g., stress, anxiety, grounding, self-trust, emotional healing, general well-being, etc.)
3. What areas of your life, mindset, or energy feel most in need of support, healing, or transformation right now? What are you ready to release? (Feel free to include anything physical emotional or spiritual)
4. Do you have any current physical or emotional issues you're dealing with? (e.g. anxiety, depression, headache, chronic pain, injuries, etc.)
5. How would you describe your stress level?

LowModerateHigh
6. How do you typically manage stress & what is your stress level 1-10 (1-low 10 -high)? (e.g. meditation, exercise, yoga, etc.)
7. Are you currently experiencing any emotional challenges? (e.g., grief, anger, fear, relationship issues, etc.)
8. Are there any recurring negative thoughts or patterns you'd like to work on?
9. Do you have any spiritual practices or beliefs that guide you? (e.g. meditation, prayer, mindfulness, etc.)
10. What are your goals for this session (e.g. Self- love, clarity, relaxation, emotional release, pain relief, spiritual alignment, etc.)
Additional Information:
1. Do you have any specific preferences for the session? (e.g. music, silence, aromatherapy, etc.)
2. Is there anything else youd like me to know before we begin?
By signing below, you acknowledge that the services provided whether energy healing, mentorship, or holistic treatments are supportive, complementary modalities and are not a substitute for licensed medical, psychological, or psychiatric care. Practitioners do not diagnose, treat, or prescribe. You agree to take full responsibility for your well-being during and after the session. All shared information will remain confidential, except where disclosure is required by law.
Consent & Disclaimer
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Client Intake Form

Additional Information:

Consent & Disclaimer