Intake Form

Thank you for booking your Crystal Therapy session!

To help you prepare for the session, please complete this intake form.

Full Name

Date of Birth (MM/DD/YY)

Preferred Phone Number

Address

City

State

Zip Code

Emergency Contact Person

Emergency Contact's Phone

What medical and/or psychological conditions should we know about?

Are you pregnant?

Yes

What is your previous experience with crystal therapy? Please share.

Have you ever undergone counseling? Please share.

Do you meditate? Please share.

What is your most volatile or vulnerable emotion?

What issue(s) do you want addressed during crystal therapy?

I feel the following emotions frequently:

I cannot feel the following emotions often/well:

How would you describe your spiritual beliefs, if any?

What holistic therapies have you tried, if any?

How familiar are you with chakras?

I am requesting the service of Wingspan Healing Arts, a practitioner, for the purpose of assisting me to access my own inner resources of therapy energy so that I may learn to heal myself. All information I have provided in this Intake and Consent Form is accurate to the best of my knowledge. I understand no guarantees or warranties are made to the effectiveness of crystal therapy, and take full responsibility for my expectations of the therapy process. I understand the associated risks of crystal therapy, if any, as explained by the crystal practitioner, and agree that it is my responsibility to seek any further information I feel I need. I understand that, while certain medical options may be explained to me in the course of my therapy, these explanations are in no way either a suggestion for medical treatment or any sort of prescription or medical directive, and do not constitute licensed medical advice. I waive any and all remedies I may have based on my own reliance on such information. I release my practitioner, as well as any of his/her assistants or related business interests, from any and all liabilities or claims of any nature that may result my participation in crystal therapy, including but not limited to damages from my failure to pursue medical attention from a medical professional, for the exacerbation of any preexisting physical ailments I may have, and by signing here, I agree to all these terms, and further bind my estate, heirs, and assigned to this release of liability.

Please re-type your Full Name here

Today's Date (MM/DD/YYYY)

Thank you for booking your Crystal Therapy session!

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