Soul Glow WellBeing, New Client Intake
Holistic Healing Support Provided by Becca Briley, Ordained SoulWorker, Master Life Coach & Hypnotherapist
Email *
Blessings on your journey to empowered wellbeing and a higher state consciousness! I welcome you to work with me 1:1 by filling out this form.
Full Name *
Birthdate *
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Phone Number *
Would you like to correspond via text message to book future sessions, or receive session reminders?
Home Address *
Emergency Contact Name (Relation) & Number *
What is your main reason for seeking support? *
How serious are you about making change in your life? *
What do you intend to gain from us working together? Please set an Intention. (You are planting a seed for manifestation here.) *
Do you understand that this will be self-funded, holistic support? *
What is the service/payment length agreement that you choose moving forward? *
Are you comfortable meeting via Zoom before we have in person sessions? *
Required
Please make payment prior to each session. *
Required
If you are working with a primary care physician or mental healthcare specialist who you need to consult with before working with Becca, have you done so? *
Do you agree to receiving confidential, self-healing support provided by Becca Briley, Ordained SoulWorker, Life Coach, Nutrition Specialist, Reiki Practitioner, Mindfulness Mentor & Hypnotherapy Practitioner? (Becca is not a licensed therapist, counselor, psychologist or psychiatrist.) *
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