Sunflower Moonrose LLC Intake Form

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Nastassia Johnson

Shamanic Practitioner, Tarot Reader, Licensed Esthetician

Sunflower Moonrose LLC

Fee for 90-minute Shamanic Journey Session: $120

In-Person Sessions available upon request

Email *

Name

Address

City

State

Zip code

E-mail

Phone Number

Birthdate

YYYY

Marital Status

Single

Married

Other

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Sex

Male

Female

Prefer not to say

Other

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Pronouns

Age

How many cups of coffee/tea do you drink per week?

How many cigarettes (packs)?

How much alcohol per week?

Clients should abstain from nonprescription drugs and alcohol before and after a session. Drugs and alcohol reduce my ability to connect with you during a session.

I understand

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Referred by

Have you experienced a Shamanic Journey before?

Yes

Not Sure

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Reason for today’s appointment?

How would you rate the present state of flow on your current life journey?

Poor

Excellent

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Are you more comfortable sitting or lying down during the journey portion of our session?

Sitting

Lying

Other

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Do you have a regular meditation practice?

Yes

I try my best.

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Are you comfortable with me holding your hand during the shamanic journey?

Yes

Maybe

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Is there anything else you would like me to know?

Are you experiencing any physical/emotional problems?

Yes

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If yes, explain

Are you comfortable with me pulling tarot or oracle cards if I feel called to do so?

Yes

Maybe

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Would you like me to wear a mask during our session? (in person)

Yes

Other

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Are you familiar with shamanism?

Yes

Other

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Are you open to me referring you to other practitioners I may feel you can benefit from seeing?

Yes

Other

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What is your favorite color?

What is your favorite smell?

What is your favorite flower?

What questions do you have before we begin?

Please note that the messages from spirit are unique to each individual. A shamanic journey session is not a substitute for medical treatment or mental health counseling. It may complement
many types of therapy.

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Nastassia B Johnson is not a doctor, nor does she practice medicine. She does not diagnose or treat for a specific illness or injury nor does Nastassia B. Johnson prescribe or adjust medications. She is also not a mental health care professional.

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By signing this form, “I” ( this client) give my consent to a Shamanic Journey session. I acknowledge I have read and understand the information below.

I understand that Nastassia B. Johnson does not guarantee any specific outcome from any shamanic journey session. I understand the session fee, cancellation policy and information outlined on this form.

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Discontinuation of any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional will be discussed with a licensed health professional. I understand that by discontinuing any such treatment or therapy I agree to hold Nastassia B. Johnson and Sunflower Moonrose LLC free from any liability, and I assume responsibility for any negative outcome resulting from discontinuing any prescribed, ordered or recommended treatment or therapy.

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I understand I am responsible to give 24 hours cancellation notice or pay the fee in full $120. All purchases are non-refundable, non-extendable, and non-returnable. All sales are final.

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Nastassia test Full Name

Date

YYYY

*Please allow up to 48 hours for an email reply for scheduling after submitting your form. I'm looking forward to working with you. :)

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