Healing Session Client Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form prior to your session. If you have any questions please email at Monica@featherandbone.org

Email *

Record my email address with my response

Client's Full Name
*

Are you a minor? If so, write the name of your legal guardian here and their relation to the client. *

You Identify as *

Female

Male

Non-Binary

Required

Address *

Phone Number *

Age *

Marital Status *

Married

Single

Life Partner/s

Emergency Contact (provide name, relation and phone number)
*

Children *

Yes

Occupation *

Have you ever been diagnosed or you suspect you suffer from any of these conditions?

Select All that apply

Any condition that requires anti-psychotic drugs

Epilepsy

Schizophrenia

Multiple Personality Disorder

Hallucinations or Delusions

Alcohol or Drug Abuse

Anxiety

Depression

Bipolar

I do not suffer from any of these conditions

Required

Are you under Psychiatric care? *

Yes

Are you in the care of a Psychotherapist? *

Yes

Are you consulting your PCP on this matter? *

Yes

Are there any physical ailments or medical conditions (i.e. allergies, heart, diabetes, epilepsy, transplants, accidents, anxiety or depression) that affect your everyday life?
*

Have you had any replacements or organ removal? *

Yes

Do you suffer from body pain? If so, could you explain where. *

What are your reasons for wanting a shamanic healing?

What is your religious background and how would you describe your current beliefs? *

Have you had shamanic healing before? *

Yes

Other:

Do you have a meditation practice? *

Yes

Have you experienced a guided meditation? *

Yes

Can you visualize?

Yes

Clear selection

Are you familiar with the energetic body system like Chakras? *

Yes

What is not working in your life, what hurts? *

Are there any negative patterns in your life you would like to overcome? *

What would you like to change in your life? *

Have you had experiences in your life which has changed you to the core?
*

Do you do community service? *

Yes

How do you express yourselve creatively? *

How would you describe your home environment? *

How would you describe your work environment? *

Are you ready to accept change in your life? *

Yes

I authorize Carmen Monica Tyler to perform any of the following (select all that apply) *

Power Animal Retrieval

Extraction Healing

Body part Retrieval

Soul Retrieval

Soul Remembering

Home/Business/Land Retrieval

Spiritual Counseling

Required

Please select the items that you agree and give your consent to. *

I read the document and understand What to Expect during my Shamainc Session.

I give consent to be touched during the session.

I consent for my session to be recorded and for the recording to be sent to me via email.

I consent for my recorded session to be shared for educational purposes and mutual protection.

I consent to be a case study which means that the session may be shared for educational and research purposes with others.

I consent to be a case study which means that the session may be shared for educational and research purposes with others but I wish to be annonymous.

My personal contact information (email, address and phone number) will remain confidential and will not.

Required

Disclaimer

Shamanic and ministerial services offered are to compliment medical and psychological advice and treatments. The client accepts all responsibility for using these services. Carmen Monica Tyler, Shamanic Minister and Practitioner, is not a licensed physician or psychotherapist. Shamanic Healing treatments are not licensed by the state of Pennsylvania but are a complementary holistic healing arts service licensed by the state. Shamanic healing is an ancient spiritual and energetic method of healing that deals with the spiritual and energetic aspect of illness and the soul. As shamanic healing deals with the spiritual aspect of illness there is no way to predict the results that will manifest emotionally or physically. Shamanic healing does not replace the need for traditional psychological and medical treatment. The information provided to you during your session is not intended to diagnose or treat any medical/psychological concerns. I advise you to contact a licensed physician or Certified Medical Practitioner for any medical/psychological concerns you may have.

I have read the above disclaimer and assume any and all responsibility during and after my shamanic healing session. A copy of this Disclosure Form will be provided upon request.

E-Sign Below *

If siginng for a minor please check the box below. *

As the legal guardian of the client I give my consent for treatment with the approval and consent of the minor .

I do not give consent to treat the minor.

N/A

Required

What is your availability?

Select all that apply

Monday - Friday early evenings

Monday - Friday during the day

Weekends

Required

I wish to work with you *

Remotely

In-Person

A copy of your responses will be emailed to .

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms