New Client Intake & Release Waiver

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I am looking forward to working with you! Please take a few minutes to fill out this form so I can get to know you and about your goals before our session.

Email *

Legal Name *

Prefered Name *

Full Mailing Address *

Phone Number *

Date of Birth *

YYYY

Please list any supplements and medications you are currently taking *

Have you ever received energy work? *

Yes

If Yes, what kind of energy work have you had and how long ago

Tell me a little about why you have reached out for healing *

What do you hope to accomplish in our visit(s)? *

Are there any physical, emotional or spiritual traumas from your past or present you would like to share? *

Are you ok with the use of essential oils? (In-person treatments only)

Yes, as diffused in the room

Yes, on my body

Yes, both in the room and on my body

No, please do not use any essential oils

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Is it OK for my hands to touch your head, hands, knees and/or feet? (In-person treatment only)

Yes

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Is it OK for the weighted tuning forks to touch your head, hands, knees and or feet? (In-person treatment only)

Yes

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In the event that you need to cancel your appointment within 24h of your scheduled appointment time, a $25 cancellation fee may be assessed. There will also be a $15 rescheduling fee for any appointments rescheduled within 2 weeks of scheduled appointment time. Please initial that you have read and understand this cancellation policy *

Would you like to subscribe to the Rise In Love Newsletter and opt in to email communications? *

Yes

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