New Client Intake

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

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

First NameLast Name
E-mail*
Phone Number*

Area CodePhone 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 the Flower 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.
Dina Saalisi is not a licensed physician or psychotherpist and makes no claims of medical treatment or cure, and does not diagnose, prescribe medication, or recommend that any person change or discontinue medication prescribed by a licensed practitioner.

Dina Saalisi is certified as: National Board Health and Wellness Coach (NBHWC); Bach Foundation Registered Practitioner (BFRP); Board Certified Hypnotherapist (ABH-CH) The healing modalities used in each session are a combination of these therapies, based on a client's specific needs.

By using Dina Saalisi Healing Arts, you acknowledge that you understand and agree to the disclosures stated above and that you take full responsibility for your own healing, health, decisions and actions.

In submitting this form, you agree to participate in the Flower Circle, which is a video recorded, online class. The recordings are available to members and participants, and your image will appear in the video.
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Transformational Healing of Body, Mind, Spirit & Soul

Thank you for your interest in the Flower Circle.