Intuitive Energy Healing Client Intake and Disclaimer Form

Name of your business here

Client Intake & Disclaimer

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number*

Area CodePhone Number

This is my*

Place of Employment:

Occupation:

Referred by:

Please understand that all information is held in strict confidentiality. It is very important that the client builds a strong sense of trust with the practitioner. If there is anything further you would like to discuss with me before the session or any boundaries that you would like to set to ensure your comfort and relaxation, please bring these issues to my attention.

If a book, article, or any written materials are ever printed including case studies, XXXXXXXXXXXXXXXX has permission to use information from my sessions, providing the names and personal information are altered sufficiently to provide significant anonymity. Please check box below

Please check one: *

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