The Heart Temple Intake
We are so happy you're here! πŸ˜€πŸŽ‰

Please allow yourself 15 minutes to complete this form.
This work together will be a unique experience where ALL OF YOU is welcome. As a holistic practitioner(s), we are interested in your life's yearnings, far beyond our time together. This will inform us towards your goals, fostering an easeful mind, empowering health in the body and a happy open heart.

Science has proven that our thoughts, emotions and beliefs have a direct correlation to the health in our body and happiness in our lives.Β 

Responding to the questions with authenticity will begin your session and will be the material we create your care plan. Taking the time to thoughtfully respond with what you are bringing with you, and what's genuinely happening in your life is fundamental to our work together. These questions are designed so you really tune into your own personal experience which will help you to begin unwinding any habits or patterns inhibiting the life you dream of.

It is only necessary for you to complete the * indicated fields.Β 
If you decide to complete the optional fields, do your best to speak in a Life AFFIRMING way. Do your best not to get lost in the old news or historical events of your life. It can be valuable and important to honor and give voice to what has led you here. Remember, where you have come from is not where you are meant to go!Β 

If you decide that you do not want to answer any of these questions, then it may inhibit us from working together.

Thank you for showing up, first and foremost for Yourself! πŸ™ŒπŸ½πŸ’―

We are so grateful and honored to serve you in The Heart Temple. πŸ™πŸ½πŸ‘πŸ½
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Email *
Full Legal Name (as shown on passport) *
The name I use / like to be called: *
Phone number *
Birthday: *
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Occupation (include hours/day/week and what kinds of activities your mind/body is applied) *
Emergency Contact (Name & Number) *
How were you referred? *
Which service(s) are you interested in? *
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Do I experience any allergies (bee-stings, latex etc.)? Β If so, what? *
Have you received massage, reiki or bodywork before? If so, when was your last session? *
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