Request edit access
Client Insight Form
Gathering client information to create an impactful nourishing session.  
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Phone Number and Time Zone *
Today's Date *
How did you find out about me or who referred you? *
If you had not had a call with me please list dates and times for availability for a  call and/or session *
Have you visited my website to view the holistic services? *
What service are you applying for? Check more than 1 if applicable. *
Have you had a consultation with me? *
Have you had energy work done before? *
Have you seen a psychic before?
Clear selection
Do you agree to take responsibility for your own life and your own healing? *
Do you agree to listen with an open heart? *
Do you agree to decide for yourself what to do with the information provided? *
Do you agree that you are the only one responsible for any healing and growth? *
Do you give me permission to view your entire being; spiritually, emotionally, mentally and physically during our time together? *
Your purpose for working with me? *
What is your emotional block? *
What do you feel like your challenge is? *
What do you feel shame or guilt around from your Childhood, Adolescence, and Adult Life? Please be honest and detailed. *
What psychical, emotional, mental, or spiritual trauma have you endure as a Child, Adolescent, or Adult and do you feel they are connected?  *
What do you feel fear or anger around from your Childhood, Adolescence, or Adult Life? Please be honest and detailed. *
What do you feel stress or anxiety around? Please be honest and detailed. *
Do you have any physical ailments, had surgeries, pregnant, implants (metal of other wise) or any other issues? Please list and describe bodily sensations of all. *
How is the relationship with family? Please be honest and very detailed. *
What time a day do you feel most naturally energized, without caffeine or sugar? Please input as hours of the day. *
What time a day do you feel most naturally fatigued?  Please input as hours of the day. *
What emotional and/or pyshcial traumas have you experienced in this life that you can recall. Please be open , honest and detailed?     *
What Medications are you taking if applicable?
What would you like to know about your life path? *
Would you be interested in hosting a group session?
Clear selection
What would you like to know about the power of gratitude and law of attraction? *
What tools are you looking to receive from a session with me? *
Are you invested in working with me for multiple sessions? *
Please address other questions/concerns here. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy