New Client Form for Healing Hands

Read Before Completing this New Client Form:

Please fill out this form if you are wanting to book in a Healing Hands session. You will only need to fill out this form initially. This form will provide me with details as to what you are seeking and to ensure I am the right fit for what you seek. 

In these sessions, I will offer guidance & support for you on a transformative journey with breath, sound, herbal offerings, and receptive healing touch.

If you haven't already booked in for your first session, you can do so here. Please be sure to complete this form before your first session.

Thank you for taking the time to connect and apply,

- Jacquie Divi
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Email *
Before applying, please be sure to read the Healing Hands offerings on my website. DivinaTemple.com/healinghands
What is your preferred name? *
Preferred pronouns?
Where do you currently reside? *
What is your phone number? *
What is your birthday? D/M/Y Feel free to include time of birth and location.
At this time, Healing Hands sessions are available between Wednesdays-Fridays.  Please let me know if this works for your schedule. *
Required
Emergency Contact (please provide a name, number and relationship)
Do you have any allergies, sensitivities or skin conditions? Please include plants, foods, medicines, everything.
Do you have any current injuries or illnesses?
Do you have any chronic conditions?
Do you have any history of injuries or illnesses?
Are there any areas of your body that you are experiencing pain or tension?
Do you currently have any mental conditions that are causing suffering?
Do you know of any conditions in your family history?
Our Healing Journey is powerful when intentional. 

We have the opportunity to share in an experience that can honor who you are, where you've been, where you are now and where you are going. 

In this intuitive process, it can be helpful for me to learn about you and what intentions you want to set with through this journey. 

Your intentions may feel clear or uncertain, all is welcome. Please provide to the best of your ability what brings you in for a Healing Hands session.

Feel free to answer as much or little as you like for the following questions. I welcome you to feel into these questions and connect with your inner guidance. 

Answering these now is not mandatory, we will certainly discuss further in our journey.
Take some time to reflect on what feels alive for you. What is life presenting at this time? Are you experiencing any particular life transitions? What has been reflected to you in your outer world? What are you noticing internally?
Feel into where you want to go in your life. Who and how you want to be. How you want to feel about yourself. Let your connection to future you guide what direction you want to move. What needs to transform to go there?
Do you have any specific intentions in our first session together?
You have the opportunity to sit with this longer, reflect on these questions, and gain clarity in your intentions. If intention setting feels new to you, or you feel unsure in anyway, we can discuss this further in our visionary journey. Feel free to write any other feelings or ideas in regards to your intent.
Is there anything else that you would like me to know?
How did you find Jacquie Divi / Divina Temple?
I acknowledge that I am voluntarily participating in doing Journey Work with Jacquie Divi. I acknowledge and understand that I am responsible for all aspects of my physical, emotional, mental health and well-being. 

I further recognize and understand that the suggestions presented to me during the session are in no way intended as substitutes for medical and/or other professional counseling; and that Jacquie Divi is not acting as licensed physician, but as a guide/ support. 

If I have any health concerns that may interfere or emerge as a result of this work; I understand that I should consult with a healthcare provider. 

In giving my informed consent to participate in the session, I hereby release from any and all claims, now or in the future, that I may have as a result of my voluntary participation in this work. 

I agree that I have read and fully understand the above statements.
 *
Required
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in my day that could have been filled by another client. 

As such, we require 72 hours notice for any cancellations or changes to your appointment. Patients who provide less than 72 hours notice, or miss their appointment, will be charged a cancellation fee.
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Thank you for taking the time to complete this application.
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