Client Welcome & Intake Packet
Prepared by Marsha | Intuitive Origins
Welcome
Welcome, and thank you for choosing Intuitive Origins. This space has been intentionally created to feel grounded, safe, supportive, and professional. My role is to gently guide you back to balance — mind, body, and soul. Please complete this intake and consent form prior to your first session so that your experience is safe, aligned, and supportive.
Client Information
Full Name:
*
Preferred Name:
Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Address:
*
City/Province/Postal:
*
Date of Birth (optional):
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Birth Location - Town, Province, Country (optional):
Occupation (optional):
Emergency Contact Name & Phone:
*
Primary Care Physician (optional):
Naturopath/Other Practitioner (optional):
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Privacy & Confidentiality
Your personal information is collected for the purpose of providing safe wellness services and is stored securely in accordance with Canadian privacy standards. Information will not be shared without written consent except where required by law.
Signature:
*
Date:
*
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Month
-
Day
Year
Date
Health & Wellness Information
Health Conditions
Headaches/migraines
Neck/back injuries
Anxiety or depression
Joint pain/arthritis
PTSD or trauma sensitivity
Allergies
Heart condition
Epilepsy/seizures
High/low blood pressure
Pregnancy
Diabetes
Recent surgery or injury
Chronic pain
Cancer (past or present)
Current medications/supplements:
Anything I should know for your comfort/safety:
Informed Consent for Services
Services provided by Intuitive Origins may include meditation guidance, energy-based wellness support, and educational discussion of herbal and holistic wellness practices.
These services are complementary wellness practices and are not a substitute for medical or psychological care. Intuitive Origins does not diagnose, treat, cure, or prescribe.
I voluntarily consent to receiving services and accept responsibility for my well-being.
Signature:
*
Date:
*
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Month
-
Day
Year
Date
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Herbal & Holistic Disclaimer
Any discussion of herbs or natural wellness options is provided for educational purposes only. Clients are responsible for consulting a licensed healthcare provider before beginning any herbal or wellness regimen.
Emotional Well-Being Acknowledgement
I understand that meditation and energy wellness practices may bring awareness to emotions or memories. I accept responsibility for communicating any discomfort and understand I may pause or stop a session at any time.
Signature:
*
Date:
*
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Month
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Day
Year
Date
Liability Waiver
I voluntarily participate in services offered by Intuitive Origins and accept full responsibility for my participation and well-being. I release and hold harmless Marsha | Intuitive Origins from liability except where prohibited by law.
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Cancellation Policy
48 hours notice is required to cancel or reschedule appointments. Late cancellations, missed appointments, or no-shows are non-refundable and non-transferable.
Signature:
*
Date:
*
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Month
-
Day
Year
Date
Testimonial Consent (Optional)
I consent to anonymous testimonials being shared for marketing
I do NOT consent
Signature:
Date:
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Month
-
Day
Year
Date
Final Agreement
I have read and understood this entire welcome and intake packet and voluntarily agree to participate in services provided by Intuitive Origins.
Printed Name:
*
Signature:
*
Date:
*
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Month
-
Day
Year
Date
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