Ancestral Healing Intake Questionnaire
Thank you for taking a moment to fill this out to the best of your ability. Please complete and submit this form at a minimum of 24 hours before our first session.

Feel free to reach out with any questions.

Email address *
Today's Date *
MM
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DD
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YYYY
Name *
Last Name, First Name, Middle Initial
Your answer
Phone *
(XXX) XXX-XXXX
Your answer
What brings you to this work?
Your answer
Please describe any family and personal history that may be relevant to the work.
Your answer
Are there any ways in which you work with your lineages or ancestors currently?
Your answer
Where are your ancestors from?
Your answer
What does your support system look like? Are there supports in place that you could share these experiences with?
Your answer
Please describe your relationship with the sacred if any.
(Religious or spiritual practices and affinities)
Your answer
Please briefly mention any experience of being in a visioning space
(Totally okay if none)
Your answer
Have you worked with any spirit guides or allies before?
Your answer
By checking the box below, you have read and agree to the following: You are responsible and able get additional support from any health care providers if necessary. There is a 24 hour cancellation and rescheduling policy, where full session fees are charged unless given 24 hours notice. Technology and even phone sessions may not always have great connection or even lose connection at times. *
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