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INTAKE FORM:
1
Your Name
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2
Your Date Of Birth
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Year
Month
Day
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3
What is your main concern you'd like to work on
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WHAT CAN I HELP YOU WITH?
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4
Other concerns
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PLEASE SCROLL DOWN AND SELECT ALL THAT APPLY
ADDICTION
ANXIETY
CONFIDENCE
CARREER
DEPRESSION
FEAR
FERTILITY
FINANCES
PHYSICAL ISSUES
RELATIONSHIPS
SLEEP
STRESS
TRAUMA
WEIGHTLOSS
Other
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5
What is your biggest worry/fear?
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WHICH AREA OF YOUR LIFE GETS AFFECTED THE MOST BY THIS?
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6
What would you like to release, attract, transform?
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WHAT ARE YOUR EXPECTATIONS FOR A SESSION?
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7
Imagine it is a year from now and it was your best year yet. What has changed for you?
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8
On a scale of 1-5, rate how true the following statements are for you.
1 = NEVER - 5= ALWAYS
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I have mental clarity & focus when required.
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I'm able to maintain peaceful & calm state during the day.
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Even when triggered, I'm able to stay proactive vs. reactive.
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I can help myself using energy healing techniques & practices.
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I am happy with my health & vibrancy.
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I know I am enough just the way I am.
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I love myself.
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I love my body.
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I feel positive about my future.
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I sleep easily and soundly through the night.
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I wake up full of energy
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I have mental clarity & focus when required.
I'm able to maintain peaceful & calm state during the day.
Even when triggered, I'm able to stay proactive vs. reactive.
I can help myself using energy healing techniques & practices.
I am happy with my health & vibrancy.
I know I am enough just the way I am.
I love myself.
I love my body.
I feel positive about my future.
I sleep easily and soundly through the night.
I wake up full of energy
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9
SELECT THE NUMBER THAT BEST CORRESPONDS TO EACH FEELING IN YOUR AVERAGE DAY
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This field is required.
1 = NEVER | 5 = EVERY DAY
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SELF HATRED
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CRYING SPELLS
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HOPELESSNESS
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NEGATIVITY
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ANGER
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LACK OF ENERGY
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SUICIDAL THOUGHTS
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SELF HATRED
CRYING SPELLS
HOPELESSNESS
NEGATIVITY
ANGER
LACK OF ENERGY
SUICIDAL THOUGHTS
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10
YOUR SIGNATURE
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