LHT Space Clearing Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address - The Location Receiving the Space Clearing
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Space Clearing Type
*
In-Person Space Clearing ($400 base rate)
Virtual Space Clearing ($350 base rate)
On-Site Commercial/Office Clearing ($600 base rate)
Approximate Size of the Space
*
Under 1,000 sq ft
1,000 - 2,000 sq ft
2,000 - 3,000 sq ft
3,000+ sq ft
Number of Rooms and Floors
*
Scheduling Preferences
*
Please Select
Within the next week
Within the next 2-3 weeks
Next month / Flexible
Intentions for the Clearing
*
Why are you seeking a space clearing at this time? Please share any specific intentions, physical areas of concern, or 'heavy' spots in the environment you would like me to focus on.
Availability Acknowledgement
*
I understand that space clearings are generally scheduled on weekdays between 9:30 AM and 2:30 PM PST.
Energetic Permission
*
I grant permission for Rosalyn Acosta to perform a brief, remote distance energy tap into my personal energy field prior to the session. I understand this is used solely to identify any energetic transference between myself and the space.
Medical Disclaimer
*
I understand that energy healing and space clearings are holistic complementary practices. They are not a substitute for professional medical, psychological, or psychiatric care. Rosalyn Acosta does not diagnose or treat medical conditions.
Property & Liability Waiver
*
I authorize Rosalyn Acosta to enter the premises listed above for the purpose of a space clearing. I agree to hold Rosalyn Acosta and Live Heal Travel harmless from any claims of liability, personal injury, or property damage that may occur on the premises during the course of the session. I also acknowledge that the practitioner reserves the right to terminate the session immediately and leave the premises if the environment is deemed unsafe, hazardous, or inappropriate at any time.
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