Client Intake Form for your session with Maya Zahira, Psychic Protection Sanctuary
Welcome to Psychic Protection Sanctuary with Maya Zahira!

Please fill out the questions below so we can make the most of our session time.

This is a very thorough questionnaire, and will assist Maya in obtaining a clear understanding of your situation and how she can best support you.

Disclaimer: Please be advised that Maya Zahira is not a doctor, therapist, lawyer, or financial adviser. As such, no part of your session should be interpreted as a replacement for medical diagnosis or treatment, or professional financial or legal advice. If you are experiencing a medical or psychiatric emergency, or if you feel you are in danger, please immediately contact 911 or your medical professional.
Today's Date *
Client Name *
Address *
Email *
Daytime Phone
Cell Phone *
Emergency Contact (Name / Phone / Relationship) *
How did you hear about Maya Zahira and/or Psychic Protection Sanctuary *
Reason for seeking session *
Have you ever had an energy healing session before? *
Are you currently under the care of a health care professional? Check all that apply. *
Have you had any surgeries? When? Describe:
Medical Issues / Health History (Check what applies.) *
(Optional) Please share any other details about your physical or mental health history.
Medications / Supplements (Check what applies.) *
Are you sensitive to perfumes or fragrances?
Clear selection
Are you sensitive to touch?
Clear selection
Do you use? (Type / Frequency?) Alcohol, recreational drugs, cannabis, tobacco, caffeine *
Clear selection
Water intake--Glasses per day:
Nutrition *
Sleep patterns *
Personal Stresses (Check all that are moderate to significant causes of stress.) *
(Optional) Please share any other details about any causes of stress in your life, current or past.
Relaxation / self-care (Check all that apply.) *
Your religious/spiritual practice and/or belief *
For your upcoming session, do you have any particular areas of concern? Describe. *
What do you believe is the reason for your current issue?
What would you like to focus on in your session?
Is there anything else you'd like to tell me?
Additional information:
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy