Holistic Intake Form

Holistic Intake Form

New client information
Personal Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name & Phone
Please include the name and phone number of your emergency contact
How did you hear about me?
Health & Wellbeing
What brings you to holistic sessions at this time?
What are you hoping to gain or experience from our sessions together?
Is there anything in your physical, emotional, or mental health history that you feel would be important for me to know?
Are you currently under the care of a medical professional?
If yes, please describe.
Are you currently taking any medications or supplements?
Is there anything I should avoid or be sensitive to during our sessions?
Energy & Session Preferences
Have you ever experienced energy healing or holistic therapies before?
If yes, what was your experience like?
Are there any areas of your life or energy you'd like to focus on?
Do you have any intentions or goals you'd like to set for our time together?
How do you prefer to receive support? (e.g., gentle, direct, reflective, grounding)
Is there anything you'd like me to know to help you feel safe and supported?
Energy Contact Consent
I understand that during our sessions, I may receive energy healing, intuitive guidance, and other holistic modalities.
Consent to energy work
Agreements & Understandings
Please be aware that during our sessions, I will be taking personal notes to support your holistic care and ensure the best possible guidance. These notes are confidential and used solely for your benefit.
I understand that the services provided are holistic in nature and are not a replacement for medical or psychological care. I understand that results vary for each individual and there are no guarantees. I agree to communicate openly and honestly and to ask questions whenever I need clarity. I understand that if at any time I exhibit signs that indicate clinical counselling or medical care would be more suitable, Tiarna Mosely - Holistic Practitioner reserves the right to refer me to appropriate professionals. I understand that Tiarna Mosely - Holistic Practitioner also reserves the right to terminate sessions if it is deemed that continuing is not in my highest good. I will treat our sessions with respect and confidentiality. I have read and understand the above.
Signature
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Holistic Intake Form

Personal Information

Health & Wellbeing

Energy & Session Preferences

Energy Contact Consent

Agreements & Understandings