Shamanic Healing Client Questionnaire
Please fill out this form and then schedule a free consultation
Email address *
Name *
Your answer
Age *
Your answer
Country *
Your answer
Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Relation
Your answer
What are your goals with Shamanic Healing? *
Your answer
Are you seeing any practitioners or therapists at this time or about issues today? *
If yes, medical, spiritual, energy, psychological, chiropractor, acupuncturist, other?
Your answer
Have you experienced Shamanic or Intuitive Energy Work before? *
If yes, for what reason and when?
Your answer
Are there any medical conditions or specific medical problems that you are experiencing at this time? Explain.
Your answer
Have you had any major losses due to death, divorce or separation? *
If yes, when and what relationship to you?
Your answer
Have you had any traumatic events you are aware of? *
If yes, when and what happened?
Your answer
Current profession? *
Your answer
Do you enjoy your job?
Relationship Status
Length of Relationship
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How would you describe your family/social life right now?
Your answer
How would you describe your childhood / relationship with parents?
Your answer
Any history of major illness/health problems/mental or emotional concerns? *
Your answer
Are you experiencing any physical problems at the moment? *
If yes, what physical symptoms are you having?
Your answer
Please indicate if you having any of the following issues?
Do you have any family patterns of disease, addiction or illness?
Your answer
Do you currently perceive stress, anxiety, panic, fear, sadness, anger, guilt, shame, depression or feeling stuck? Have you been affected in the past? Explain.
Your answer
Have you ever been hospitalized for physical health, mental health or substance abuse treatment? If so, please list reason.
Your answer
Do you currently have a spiritual practice currently? If so, please explain.
Your answer
If yes, what forms and how frequently?
Your answer
Are you sensitive to energies or feel you have taken on energies from other people or environments? Describe.
Your answer
What are your greatest strengths, talents and resources?
Your answer
What do you want to do that you are not able to accomplish at this time? *
Your answer
What other things would you like to work on?
Your answer
Any further questions for me?
Your answer
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