Energetic Healing Intake Form
Be grateful to yourself!  You have set the intention to write a new chapter in your life!  This is the beginning of you aligning with your best self.  I'm looking forward to accompanying you on your journey but I need to know some history first.   

We are creating a loving, protected and safe space together! All information here and in any of our sessions is completely confidential. 

Lots of Love - Jessica
Sign in to Google to save your progress. Learn more
Name *
Pronouns
Clear selection
Birthdate
MM
/
DD
/
YYYY
Phone *
Email *
Address
Where did you find me?
Do you have any expectations for our session?
Sun Sign
Please list the names of your parents and how your relationship is.  Please note if they are not with us anymore and when they transitioned.
Please list the names of your siblings and how your relationship is with them.  Please note if they are not with us anymore and when they transitioned.
Are you in Relationship or Have Been Married?  Please List Name 
Do you have children? If so please list names, ages and any health issues
What do you do for work? Are you happy in your position?
Next
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