Ignite Your Fire Coaching Program
Intake Form
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First and Last Name *
Preferred pronoun
Phone Number *
Email Address *
Full Mailing Address (street, city, state, zip) *
3-month or 6-month coaching program? *
What do you hope to gain most out of this coaching program?
What area of your life do you feel most challenged by?
If you could be, do, or have anything, what comes to mind first?
What were your greatest interests when you were between 4-10 years old?
Is there anything else you want me to know?


I, the person receiving the energy/coaching session, understand that the techniques and recommendations being provided promote a cooperative model to bridge holistic healthcare with traditional medicine. These techniques/recommendations are intended to enhance my own healing process and do not replace traditional medical healthcare. I understand my Energy Practitioner/Coach does not diagnose, prescribe medications or perform surgery and that I should refer to a licensed medical doctor for traditional medical care or for questions concerning specific illnesses.

I understand and agree that I am solely responsible for consulting a medical doctor in any case of physical, mental, or emotional illness. I agree to keep my Energy Practitioner/Coach informed of any changes in my condition as this could affect future sessions. Additionally, I grant permission for the Energy Practitioner/Coach to speak with my medical doctor.

I acknowledge that the session described above, as administered by the Energy Practitioner/Coach, is offered as an adjunct to, but not a substitute for, medical care. I understand that the Energy Practitioner/Coach is not a licensed medical doctor. I hereby waive all rights to any cause of action against the Energy Practitioner/Coach, or their assigns or beneficiaries, stemming from their session with me. This waiver also binds my agents, assigns, and beneficiaries.

Please sign and date below

I will email you an invoice upon receipt of this intake form. Once I have received payment, I will contact you to schedule your first session. How do you prefer to be contacted? *
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