Intake Form

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Health History

Do you have frequent headaches?

Have you ever had any surgery?

Do you have any spinal issues?

Do you experience chronic pain, if so where?

Are there any other medical conditions or concerns you would like me to be aware of?

Have you had any traumatic events or experiences in your life that you would like to share with me?

Details

What Is A Remote Healing Session?

My role is to hold sacred energetic space to guide you deeper on your healing journey. I have been taught to run earth energy through my body to help you achieve energetic harmony. This is done by working with areas of chronic pain and your chakras. The main ones I work with are the seven energy centers in your body that regulate the flow of energy throughout our systems. (Stress or tension can be held in these energy centers.) The goal is to help you find a mind/body/spirit connection, reduce the pain you feel, and help you on your journey of self-healing. I am not a doctor, I do NOT diagnose.

During Your healing:

At our scheduled session time you can do anything you like. (Sleep, go to work, relax, exercise, etc.) I open our session with a distance reiki symbol which connects me to your energy field. I then let your energy system guide me to areas of need. Our session will be one hour in length during which you may feel very relaxed, emotional, or charged. To close our session I seal in my work and close our connection.

Follow Up:

After our session, I will follow up with detailed notes of what I worked on.

Cancellation Policy:

Please email me 24 hours in advance in order to receive a full refund.

Privacy:

Your healing sessions will remain confidential.

Signature

Date

Health History

Details

READY TO DIG DEEP?

Ready to dig deep?