Client Intake Form
Please fill out the form the best you can and complete the section(s) that is/are most appropriate for your upcoming session(s): Chakra Reading & Balancing, Emotion/Body/Belief Codes and/or Reiki
Today's Date:
First Name:
Last Name:
Date of Birth:
Parent/Guardian's First/Last Name (if client is under 18):
75
Street Address:
City, State, ZIP Code
Phone/Cell:
Email:
How did you hear about Intuitive Healing with Janice?
How would you like to receive updates?
Email
Text
Both
I would like to be added to your mailing list
Have you ever had a Reiki session before?
Yes
No
Have you ever had an Emotion/Body/Belief Code session before?
Yes
No
What specific issue(s) or goal(s) would you like to work with within our session(s) together?
Are you familiar with a Chakra Reading and balancing of the chakras?
Yes
No
Not sure
Are you pregnant?
Yes
No
Do you have a pacemaker?
Yes
No
Please check any condition(s) you are currently experiencing:
Allergies
Arthritis
Blood Pressure (high/low)
Cancer
Diabetes
Epilepsy
Heart Disease
Paralysis
Phobias
Stroke
TMJ
Other
No current conditions
If you checked OTHER, please explain:
Please check any current symptoms you are experiencing:
Blurry Vision
Carpel Tunnel
Constipation
Diarrhea
Dizziness
Fatigue
Headache
Indigestion
Insomnia
Physical Discomfort
Poor Appetite
Other
No current symptoms
If you checked OTHER, please explain:
SUBMIT