New Client Intake

Transformational Healing of Body, Mind, Spirit & Soul
Thank you for your interest in the Healer's Circle.

So that I may better understand your healing goals and desires, please complete and return this form. Love & flowers, Dina 🌷
Name *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Do you have any health concerns? If so, please describe. *
Have you participated in a support group or healing circle before or are you currently in one? If so, please share the nature of the group. *
What do you wish to achieve by participating in Healers Circle? *
Please give details of any of the above or anything else you would like to share:
The intention of Dina Saalisi Healing Arts is to provide you with

guidance and support for healing the body, mind, spirit & soul.
Should be Empty:

Thank you for your interest in the Healer's Circle.