Client Intake Form

First Name *

Last Name *

Email Address *

Phone Number *

Please choose the type of healing you would like from the options below:Energy Healing – for IndividualsEnergy Healing – for Seniors (65+) & First RespondersTantra Meditation – for IndividualsTantra Meditation – for CouplesResonance HealingGestalt, Meditation & Yoga Session

Please describe in more detail what you require support with: *0 / 300

Please list any past or current injuries:e.g. physical injuries such as; shoulder, knee, etc0 / 300

Are you taking prescribed medication:YesNo

Please list medications and what they are prescribed for:

Please list any allergies (incense, perfume, essential oils, etc) :

Please fill in the form below to book a Healing and we will be in touch shortly.