Intake Form
Please copy, print, complete and bring with you to your first session. Thank you.
Name: ____________________________________________________________________________________________
Address: ____________________________________________________________________________________________
____________________________________________________________________________________________
Date of Birth:________________________ Blood Type: _____________________
Home Phone: ______________________ Cell Phone: _____________________
Work Phone: _______________________ E-Mail: __________________________
Yes No You may add me to your mailing list for services/events/activities offered.
Best time to contact: ___________________________________________________________________________________
Occupation: ___________________________________________________________________________________________
Referred by: ___________________________________________________________________________________________
Please check all that apply that you desire to participate in.
Reflexology _________ Total Body Modification _________
Aromatherapy _________ Natural Healing Vials _________
Reiki/Karuna _________ Weight Loss _________
Body Sculpting _________ Life/Wellness/Spiritual Advisement _________
Cold Laser _________ Chakra Clearing/Balancing _________
Energy Work _________ Total Relaxation/Clearing _________
Emotional Release _________ SPMI/Sadhana _________
What brought you to the office today?
Brief description of your desired health goals session(s):
