Intake form

Full name

Date of birth

Phone number

Email

Emergency contact and phone number

Are you suffering from any illness, physical injury or mental health condition? Are you suffering from any illness, physical injury or mental health condition? Yes No

Please provide details on your health.

Are you currently taking any medication? Are you currently taking any medication? Yes No

Please provide details on your medication.

Please tick all that apply Please tick all that apply Heart disease or heart attack Asthma or respiratory issues Seizures or epilepsy Anxiety or panic attacks Depression High or low blood pressure Pregnancy

Do you have any allergies (e.g., to essential oils, scents)? Do you have any allergies (e.g., to essential oils, scents)? Yes No

Please provide details on your allergies.

Anything else that you should make me aware of?

Have you participated in energy work before? Have you participated in energy work before? Yes No

Please describe your previous experience.

Do you practice any form of meditation, somatic exercise or breathwork regularly? Do you practice any form of meditation, somatic exercise or breathwork regularly? Yes No

What type and how often do you practice?

What are you hoping to achieve from this session? (e.g., relaxation, emotional release, healing, clarity, etc.)

I understand that energetic bodywork involves various techniques that may evoke physical, emotional and mental responses. I acknowledge that I am responsible for consulting with my healthcare provider if I have any concerns. I am taking full legal and personal responsibility for myself during the session and for the outcomes of it. I have read and agreed to the general terms & conditions on this website. Your consentYes, I consentNo, I do not consent

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