Client Intake Form

All information provided is private and confidential.

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

(* Required)

    Full Name*
    Address*
    Postal Code*
    City*
    Country*
    Mobile number*
    Email*
    Sex

    Date of Birth

    Occupation

    Women Only: Are you pregnant?

    Emergency contact

    Emergency contact's phone

    Are you currently under the care of a physician?

    If yes write his/her phone number

    Please list any health issues or requirements you would like me to know about (include health restrictions, allergies, or other health concerns)

    Reasons for seeking Healing?

    Are you taking any medication?

    Do you take recreational drugs and if so, what?

    Have you ever been in/going into hospital for surgery, mental or emotional illness?

    Please list any injuries you have or had

    Please list any traumatic or major life-threatening events that occurred in your life and what happened

    What would you like to achieve from these sessions?

    Do you have any additional comments or questions?


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