Intake
 
Email *
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Name *
Email *
What is your primary goal or intention?
What support would you like on your journey?
How do you nurture your well being?
Do you have any pre-existing physical, emotional or mental health concerns? *
Are you currently under the care of a physician, psychiatrist or therapist? *
Do you have a dissociative disorder? *
Are you released to exercise? *
Are you currently on any medications?  If so, what for?
How are you managing your past injuries, accidents, and or mental illness?
Do you have any limited range of motion? *
Do you have any images, animals, places, things, colors or topics that cause stress or you would rather not be used in meditation or for guided imagery? *
Have you experienced trauma or a traumatic event? *
I acknowledge this participation may be physically and or emotionally intense and  that I am in good emotional, mental and physical health to participate. I am authorized by my physician to participate and I acknowledge that it is my responsibility to inform my service provider of any pre-existing medical conditions, mental health or injuries know or unknown  that may impact my ability to participate.   *
I understand that the services provided do not include the practice of medicine and that my service provides is not a licensed physician. These services are non-diagnostic. *
I hold myself accountable for my own actions and acknowledge that it is my choice to participate in services at my own discretion. I understand that it is my right to discontinue at any time. *
Emergency Contact *
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