Waking the Dream Intake Form
Full Name
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E-mail address
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Phone Number
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Birth Month & Day (omit year)
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I am interested in the following consultations:
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Gateway Dreaming
Life Coaching
Intuitive Counseling
Meditation Instruction & Guidance
Creative Visualization & Guidance
Creative Writing Instruction & Guidance
Acoustical Journeys / Sound Healing
Reiki / Energy Balancing & Time Management
Other
Lifestyle & Daily Experiences
What foods do you eat and/or dietary practices do you enjoy?
How many hours do you sleep each night?
How often do you exercise?
1/week
2/week
3-4/week
5+/week
None
How often do you drink alcohol?
1/week
2/week
3-4/week
5+/week
None
What leisure activities do you enjoy? How often each week?
What is your primary occupation? How many hours per week do you work?
Background & Personal History
Please briefly note major life events from the last 6-8 years that you have experienced, and when they occurred. (Ex: house move, change of job, marriage, divorce, etc.)
Please note any history of trauma or chronic illness.
Please note any pertinent familial history, including any challenges with any familial relationships.
What challenges, if any, are you currently experiencing in your life?
How often do you remember your dreams?
3+/week
1-2/week
1/week
2-3/month
Rarely
Never
Other
Do you experience any recurring dreams?
Yes
No
If yes to the above, please explain.
Do you experience any recurring nightmares?
Yes
No
If yes to the above, please explain.
What recent achievements, successes and personal growth have occurred for you? (1-2 years)
Session Goals & Desired Experiences
What improvements in your life would you like to experience?
What is your primary goal with our sessions?
What additional goals for personal growth do you have?
Have you worked with other energetic or healing modalities? If so, which (i.e. Reiki, Cranial Sacral, etc.)?
Please include any additional information that may inform our sessions.
Consent for Consultation
By submitting this form and participating in consultation services from Waking the Dream, LLC and its practitioners, I agree to the following: I understand that personalized consulting sessions are not intended to diagnose or treat any medical condition or disease. I also understand that personalized consulting sessions are not a substitute for medical, psychological, or psychiatric evaluation, maintenance, or care. I understand that at all times I have the choice to participate in consultation sessions from Waking the Dream, LLC and that at any time I may cease to participate in said sessions without penalty, with the exception of monies owed for services rendered. Further, I agree to hold harmless Waking the Dream, LLC and its practitioners for any results of any consultations for which I voluntarily choose to participate. All personal information is kept secure and confidential.
Check here to consent
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I consent to consultation.
Payment Policy
By submitting this form and participating in consultation services from Waking the Dream, LLC and its practitioners, you agree to the following: Personalized consulting sessions are pre-paid or shall be paid at the time of services. Waking the Dream, LLC does not accept any forms of medical health insurance and is not a health care provider.
Cancellation Policy
By submitting this form and participating in consultation services from Waking the Dream, LLC and its practitioners, you agree to the following: Personalized consulting sessions are subject to scheduling and availability. Payment is due in advance, or at the time of services. Cancellations should take place no less than 48 hours in advance of the scheduled session time. Should a cancellation occur less than 48 hours prior to the scheduled session, payment for the session shall still be required.
Check here to consent
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I have read and understand the payment policy and the cancellation policy, and agree to payment terms.
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