Application and Release Form

Name*

First NameLast Name

Gender/Preferred Pronouns*

Mailing Address (We send gifts!)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Date of Birth

MonthDayYear

Age

What is your Human Design type (Generator, Manifestor, Projector, Reflector, or ManiGen), profile (ex: 5/1), & authority (splenic, sacral, emo, or lunar)?

How did you hear about/find Nikki Ananda?*

Which program/service are you interested in?*

If "other" please specify:

What are you social media handles? Where can I find you?

Tell me a little bit about yourself and your lifestyle! What do you do for work? What are your interests? How do you spend your leisure time? Do you have any pets? *

What are your intentions for our work together?*

What brings you here? I would love to hear a summary of what calls you to the work now. What are current events and themes that are happening in your life? What are the important areas you are wanting to focus on? *

For women: Have you done any womb or sacred sexuality work in the past? If yes, please describe.

For women: Do you have any health conditions that should be considered for embodiment practices? If you are interested in Venusian Bodywork sessions, please make sure to name any breast, abdominal, and GI conditions as well.

Are you currently seeing any healthcare professionals (mental and/or medical)?

How high is your desire/priority to up-level in the areas of focus below.*

	Zero	Minimal	Moderate	High
Romantic Relationships
Business
Money
Spirituality
Sexuality
Body/Embodiment
Priestess Temple Arts

Please take a moment to consider how much time you have for each of the following.*

	Zero	Minimal	Moderate	High
Self
Embodiment Practices
Relationship (s)
Spirituality
Community

LEGAL DISCLAIMER
While I have training and experience in all of the services that I provide, I am not a licensed health care professional. Therefore, Nikki Stearns (Nikki Ananda) cannot be relied upon to properly treat, diagnose, or advise any of her clients or participants. The services provided through Nikki Stearns are offered with the view that each individual is ultimately responsible for his or her decisions, actions, and behaviors. Services provided by Nikki Stearns are not intended to be a substitute for professional mental health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding health conditions. In no event shall Nikki Stearns be held liable for any direct, indirect, incidental, consequential, or punitive damages resulting from engagement with any of her services herein.

I have the read and agreed to the legal disclaimer.*

Agree

Thank you for your application! I will be emailing you within 48 hours. If you do not see an email from me by then PLEASE CHECK ALL YOUR EMAIL FOLDERS.*

I acknowledge that emails from nikki@nikkiananda.com may need to be manually whitelisted through my email server.

Signature

Client Application and Liability Release