First Name *

Last Name *

Best number to contact you *

Email *

Instagram / Facebook Profile Link *

What is your deep intention for joining this healing space? *

Please describe any specific physical or emotional concerns you would like to address during the session. *

On a scale of 1 to 10, how would you rate your current overall well-being? (1 being very poor, 10 being excellent) *

1

2

3

4

5

6

7

8

9

10

Are you currently taking any medications or have any medical conditions we should be aware of? *

Have you experienced energy healing before? If yes, please describe your experience. Or N/A if you have not. *

Are you willing to refrain from any alcohol or intoxicants a week prior to the session? *

Yes

No

I'm not sure

How comfortable are you with physical touch during a healing session? *

Very Comfortable

Somewhat Comfortable

Neutral

Somewhat Uncomfortable

Very Uncomfortable

Do you have any allergies or sensitivities (e.g., to essential oils, incense)? *

Which of the following healing tools are you most interested in experiencing during the session? *

• Meditation
• Reiki Healing / Energy Healing
• Sound bath
• Emotional Awareness Talk
• Somatic Practice
• Oracle Card Reading
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What specific outcome or feeling do you hope to achieve by the end of the session? *

How did you hear about our healing sessions? *

• Referral
• Social Media
• Website
• Online Search
• Other
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WAIVER: By answering YES below, I agree to take full responsibility for my action and inaction prior and subsequent to my session. In signing up for the Heart Healing Session, I confirm that I accept responsibility for informing the facilitator about any medical condition, mental health condition, pregnancy or changes to my health that may affect my physical and mental health during and after the session. I am aware that results may vary from person to person and I waive any legal action against the facilitator. I also understand that payments made are non-refundable but transferable. I am willingly undergoing this session with no expectation on results. *

Yes, I agree

No, I am not signing up

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