Nativa Wellbeing Client Intake Form
No information about the client will be discussed or shared with any third party without written consent of the client.
Email address *
Full Name *
Your answer
Your Birthday *
MM
/
DD
/
YYYY
Phone Number *
Your answer
Emergency Contact *
Your answer
Do you have a particular area of concern physically or emotionally? *
Your answer
Do you have any sensitivities or allergies? *
Your answer
What 3 words describe your ideal state of being? (example: Happy, Healthy, Confident) *
Your answer
Is there anything you would like to share?
Your answer
How did you hear about Nativa Wellbeing?
Your answer
I understand that energy healing is a hands-on practice that is used for stress reduction and relaxation. I understand that energy healing practitioners do not diagnose conditions nor do they prescribe or perform medical treatment nor interfere with the treatment of a licensed medical professional. I understand that energy healing does not take the place of medical care. It is recommended that I see a licensed physician or professional for any physical or physiological ailment I may have. I understand that energy healing can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that any improvements I wish to experience from energy healing require that I too take time to care for myself with love and attention.
Please type your name if you have read and understood the above paragraph. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Nativa Wellbeing. Report Abuse