Portal of Rebirth Intake & Waiver Form

Portal of Rebirth Intake & Waiver Form

Please fill out this confidential intake and waiver form before your session. Your responses help us support you best and ensure you have read and agreed to all required policies.
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Disclaimer (Please Read)

The client who requests and agrees to receive psychic reading or healing session acknowledges that it is a potentially powerful mental and physical regulating tool. The client understands that personal results will vary and there are no expressed or implied guarantees or warranties of results. Further, the client is aware that the psychic reading/healing session is spiritually-based in nature and any information that comes through is coming from their soul (also known as "Higher Self," "Subconscious," "Oversoul," "Higher Conscious," "Christ Consciousness," etc.) If the client receives information from their Soul regarding any lifestyle changes or changes in their health protocols, the client takes full responsibility and will take it upon themselves to consult their healthcare provider if the client deems necessary after their session.

Waiver of Liability

The client voluntarily agrees to be a subject of psychic reading/healing session, which involves quantum healing, hypnosis, spiritual coaching and counseling, and past life regression. Except in the case of gross negligence or malpractice, I and/or my representative(s) agree to fully release and hold harmless, Anastasia Martynova, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session.

Methods Used by Anastasia Martynova

Anastasia Martynova employs intuitive reading, hypnosis, her intuitive abilities, and spiritual coaching techniques to facilitate the clients desire for self-improvement. Specific techniques may include body relaxation, guided meditation, spiritual psychology, past life regression, Reiki, behavior modification, and intuitive insight.

Cancellation and Refund

For all offerings, there is a 24hr cancellation policy. If you cancel your service at least 24 hours in advance, please contact us by email or phone and we will provide a full refund. We do not offer any refunds for services that have already been rendered. Cancellation must formally be made in advance via phone or email for any potential refund. All No-Shows and appointments cancelled or rescheduled within 24 hours of the scheduled appointment time will automatically be charged the full cost of service.
Easily triggered emotions
Nervous habits/Phobias
Tendencies to overeat, consume sugar/caffeine or alcohol/tobacco
Tendencies to consume drugs (over the counter, prescription, “other”)
Depression or other emotional issues
Medical conditions (Are you seeing a doctor and/or taking any medications?)
List major illnesses, operations, accidents or trauma (including abuse) with approximate age
Do you have a weak/vulnerable part of your body (health or otherwise)?
What tends to bring you stress?
Where do you feel/hold stress in your body?
What were you like as a kid?
What tends to bring you relaxation/joy?
What do you love most?
List your “top” personal goals in order of importance to you
What do you feel is your life’s purpose?
What would you like to accomplish with your sessions?
I have read and agree to the Disclaimer, Waiver of Liability, Methods Used, Sessions are Recorded, Healing Session Fees, and Cancellation and Refund policies above
Signature
Date

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