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*
    Mobile or Home Phone number*
    Email*
    Address*
    City*
    Postal Code*
    What is/are the reason/s for contacting me? Please provide as much information as possible
    How did you find me? (check all the applicable)
    Search Engine (like Google)Friend/AcquaintanceSocial MediaReferred by Physician/Complementary Health PractitionerOther
    Consent Form
    I understand that the Reiki/healing treatments, Hypnotherapy/Past Life Regression sessions given by Giancarlo Serra involve a natural method of energy balancing for the purpose of stress reduction, relaxation, and healing. Giancarlo Serra will not interfere with the treatment of a licensed medical professional.

    I also understand that it is not therapy or a replacement for medical treatment. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I have.

    I understand that I accept total responsibility for my own health care and maintenance. Nothing said, typed, printed, or produced by Giancarlo Serra is intended or meant to diagnose, prescribe, treat a disease, or take the place of a licensed physician.

    By signing below, I acknowledge and fully agree with all the above information.
    Signature date

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