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Everything Always Works Out
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New Client Intake Form
First name
Last name
Email
Phone
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Occupation
Education
Emergency Contact Name
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Do you have any experience with any kind of energy medicine modality?
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No
If yes, please provide types of energy medicine modaility you've experienced.
Please provide a description of current relevant expressions; physical, mental, emotional, spiritual, relationships, and creativity. Share any interference with your ability to experience a joyful and fulfilling life.
Please share your spiritual or religious beliefs or practices.
Are there any specific ways you like to connect for spiritual support?
Please share any word or name you us to descibe the Devine.
Please list sources of relaxation or self-care:
Do you regularly consume any of the following?
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Required
Caffeine
Alcohol
Sugar
Gluten
Dairy
Fast Food
Big Pharma Products
Other
Are you addicted to any of the following?
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Required
Gambling
Gaming
Internet/Social Media
Shopping
Hoarding
Work(aholism)
Caffeine
Nicotine
Food
Overexercise
Marijuana
Prescription Medication
Alcohol
Cocaine
Methamphentamine
Heroin
Sex/porn
Other
Do you enjoy any of the following embodiment practices?
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Required
Yoga
Breath work
Tai Chi
Pilates
Dancing
Walking
Hiking
Running
Swimming/Aquatics
Strenth-training
Other
Is this your first time attending?
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No
How do you express your creativity that feel joyful and fun?
What, if anything, do you dream you couild do or be in your life?
What are your greatest strengths?
Is there anything else you would like me to know?
How did you find out about me?
I give a free session for referals, who can I gift?
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