Energy Balancing Intake
Please provide the following information to help us understand your energy needs.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Energy Healing
Energy
plus Fascia Release (target point)
What brings you in for an energy healing/ balancing session?
Stress or feeling overwhelmed
Relaxation
Feeling emotional drained
Physical Discomfort
Sleep Support
Grounding
Self-care/ general wellness
Curiosity/exploration
Releasing
Other
Describe any health conditions or medical care you are currently receiving?
Have you ever received energy healing?
Please Select
Yes
No
Where do you currently experience discomfort, tension, pain or restriction?
Neck
Shoulders
Upper Back
Mid Back
Lower Back
Hips
Head
Jaw
Arms/Hands
Legs/Feet
Abdomen
Other
If you selected other, where is the discomfort?
On a scale of 1-10, how would you are the current level of discomfort? (10 being highest)
How long have you been experiencing this physical discomfort?
Submit
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