Client Intake Form

New Client Intake Form

Please take a few minutes to complete this form prior to your initial appointment. This form is required for Energy & Soul Illumination Healing Sessions only.

* Indicates required field

Name *

First

Last

Phone *

Email *

Address *

Emergency Contact Name & Phone *

List current Medications/Supplements/Vitamins & dosages being taken: *

List any allergies below. *

Are you currently under the care of a physician? *

Yes No

If under the care of a physician, include a general description here: *

What areas do you want to focus on during your session? Describe below. *

What are your goals for your session? Describe below. *

Include any additional information helpful to know prior to your session *

How did you hear about us? Select all that apply. *

Web search Referral (friend/family/co-worker) Referral (healing practitioner) Other

If your referral source is a person, please include his/her name below. *

By selecting the "Yes" option below, you agree that the information provided is accurate and authorize this as your electronic signature. *

Submit