Individual Sessions with Georgina Peard
Thank you for your interest and trust, requesting a session with me. I wish to respond in service to your motivation and needs so this form will help you reflect and refine these before we meet, and give me some insight to prepare and hold a safe container for you.

Respond as best you can, from your heart, with what comes in the moment, and we will discuss further when we meet.

This information is completely confidential and only for me to see in relation to this session. There are no trick questions and you can change your mind later of course, and modify anything when we meet. If you do not feel comfortable to answer any question, please just write that.

Thank you. I look forward to supporting you.
Georgina / 0041 79 219 4407
Email *
Full Name *
Contact phone number *
Full Address - Street, Number, Postal Code, and City (for invoice / receipt for your complementary insurance) *
Gender *
Age *
Nationality / Land(s) of origin / Tribe or Culture *
Why are you requesting this session? Short background/context of your current situation / enquiry, and how you are feeling. Please name any enquiries, concerns, challenges, emotions or changes, and how it feels for you. *
What is your intention / longing for this session? What are you hoping for / enquiring about / releasing / calling in / activating in your life and / or relationship? Please respond from your heart. *
Do you have specific expectations? Do you have a particular type of session / type of support you would like from me? Do you have specific needs? *
Do you have any experience with healing bodywork, shamanic or tantric bodywork, or somatic sexual healing? *
How is your physical health? Aches & pains - chronic conditions - gynaecological issues - surgery etc. For women please refer to your monthly cycle / menopause. For sexual healing sessions please refer to your sexual health. *
Any episodes, and/or current medication for psychiatric or emotional conditions. (e.g. depression, anxiety, burnout, psychosis, bi-polar disease, obsessive compulsive behaviour, eating disorders, addictions)? *
Do you feel your body holding any unintegrated trauma? Have you experienced in your life any physical, emotional, mental or sexual abuse? Please explain briefly, including any therapeutic processes. *
Current intimate relationships (children, partner, married, single, lovers, widow(er) etc.) *
Are you following a spiritual path? Do you have a regular meditation and embodiment practice (e.g. yoga, qi gong)? *
New clients: How do you know of me?
Questions / Comments
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy