Quantum Alchemy Intake Form

Client Information Form

Fill out this form to book your session
Full Name*

First NameLast Name
Email*
example@example.com
Age as of right now*
Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List 2-3 issues you want to heal - add in as much details as you'd like
Rate your top priority issue on scale of 1-10

1

2

3

4

5

6

7

8

9

10

1 is Lowest level of discomfort/pain, 10 is Extreme level
Which program are you interested in*
Has somebody referred you?*
If you answered YES, Please list their name so we can Thank them
Investment acknowledgement *

The investment to work with me starts at $5k for Quantum Alchemy and goes up to multiple five figures, depending on the duration of the services agreed upon. There are always customized payment plans and subscriptions offered to facilitate ease for the clients, which can be discussed on our preliminary call. Please check the box to confirm that, while there is no obligation, you understand the level of investment required, and that you are in a position to finance your decision should you decide to step into one of my bespoke programs.
CONSENT
- You understand your participation in these healing sessions will not treat or diagnose any disease, illness, or ailment and if you should experience any such issues you should see your registered physician or other practitioner as determined by your own judgment.
- You understand this session is not a substitute for health care,medical or nutritional advice of any kind.
- You understand and agree that you are fully responsible for your mental well-being, mental, and physical choices and decisions during and after the Session.
- You understand that we do not offer any representations, warranties, or guarantees,verbally or in writing, regarding any results of any kind.
- You give consent to aishaheals to connect with you energetically during the session in order to perform the healing.
All the information shared by the client and all the record of session reports is kept confidential and not shared with anyone without client's consent.
Yes I give my consent
Any additional info you want to share
Should be Empty:

Client Information Form