Intake Form

Please fill out the following intake form prior to your intensive. Submissions 48 hours in advance are appreciated.

Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Phone

(###)

###

####

Email Address

Referred by

If referred by a client, who was it? If other, please explain.

1. Do you have a preferred theme for your intensive?

Yes

No

a. If yes, what is it?

e.g. Heart opening, trusting myself, worthiness, abundance, building my intuition, healthy relationships, inviting love, etc.

2. Have you experienced any trauma in the past year?

Yes

No

a. If yes, what happened?

3. What is the biggest challenge in your life right now?

a. How long has this been a challenge?

4. If healing allowed you to accomplish only one thing, what would you want that thing to be?

5. List current or recents types of Healing, Therapy, Courses, etc.

6. Sign up to receive inspiring updates and a complimentary meditation

We respect your privacy

Yes

No