Intake Form For questions, please submit this form below: Name * First Name Last Name Phone * (###) ### #### Email * Do you have any experience with somatic healing? * Yes No What areas in your life would you like to improve? * Are there any specific physical areas in your body that you want to focus on healing? * Do you have any experience with energetic healing i.e. Reiki, reflexology, acupuncture, aura clearing (if so, which)? * Do you have any experience with breath-work? If so, what type of breath-work? How long have you been practicing? What type of setting (i.e. in-person class, online, 1 on 1)? * On a scale of 1-10, how stressed do you feel on average? (1 being the least stressed, 10 being the highest) * 1 2 3 4 5 6 7 8 9 10 Do you experience anxiety? If so, how often? * Do you experience depression? If so, how often? * How much sleep are you getting at night? * What is your diet like? * Do you have any allergies? * Do you have any medical conditions or physical disabilities (if so, please list below)? * Have you been pregnant or trying to get pregnant over the last 3 years? * Yes No Do you have any self-care practices (if so, list below)? * How do you take care of your mental health and emotional wellbeing? * What do you do for work? * If we are a fit, what are your top 3 goals for our sessions? * What are your top 3 results you want to achieve from our sessions? * Thank you!
