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.
Emergency Contact (Name / Phone / Relationship)
How did you hear about Maya Zahira and/or Psychic Protection Sanctuary
Psychic Protection Sanctuary YouTube channel
Friend or family
Met at a live event
Read one of Maya's books
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.
Counselor / Therapist
Have you had any surgeries? When? Describe:
Medical Issues / Health History (Check what applies.)
Serious accident / trauma
Sexual assault / abuse
Alcohol / Drug / Addiction
High blood pressure
(Optional) Please share any other details about your physical or mental health history.
Medications / Supplements (Check what applies.)
Over the counter medicine
Vitamins / Supplements / Herbal remedies
Are you sensitive to perfumes or fragrances?
Are you sensitive to touch?
Do you use? (Type / Frequency?) Alcohol, recreational drugs, cannabis, tobacco, caffeine
Water intake--Glasses per day:
Poor (mostly junk food)
Average (some junk food, some health)
Sleep is not restorative
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.)
Exercise / sports
I don't do much self-care.
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?
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