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.

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Client Name *
Your answer
Address *
Your answer
Email *
Your answer
Daytime Phone
Your answer
Cell Phone *
Your answer
Emergency Contact (Name / Phone / Relationship) *
Your answer
How did you hear about Maya Zahira and/or Psychic Protection Sanctuary *
Reason for seeking session *
Your answer
Have you ever had an energy healing session before? *
Are you currently under the care of a health care professional? Check all that apply. *
Required
Have you had any surgeries? When? Describe:
Your answer
Medical Issues / Health History (Check what applies.) *
Required
Medications / Supplements (Check what applies.) *
Required
Are you sensitive to perfumes or fragrances?
Are you sensitive to touch?
Do you use? (Type / Frequency?) Alcohol, recreational drugs, cannabis, tobacco, caffeine *
Your answer
Elimination
Water intake--Glasses per day:
Your answer
Nutrition *
Required
Sleep patterns *
Personal Stresses (Check all that are moderate to significant causes of stress.) *
Required
Relaxation / self-care (Check all that apply.) *
Required
Your religious/spiritual practice and/or belief *
Your answer
For your upcoming session, do you have any particular areas of concern? Describe. *
Your answer
What do you believe is the reason for your current issue?
Your answer
What would you like to focus on in your session?
Your answer
Is there anything else you'd like to tell me?
Your answer
Additional information:
Your answer
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