Boudica Spirit Intake Form

Boudica Spirit Intake Form

The information you provide in this form will only be used by your energy healer for session purposes only and will NOT be shared or sold to any persons or professionals.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Type of Phone*

CellLandline
If Cell, Can we text to this number? (no propaganda will ever be text by us to your phone)*

YesNo
Email*
example@example.com
Preferred Gender*
Marital Status*
Emegency Contace*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Type of Phone*

CellLandline
Mark all that apply to you*

AbdominalAcneAllergiesArthritis/Joint PainBack PainBirth ControlBlood Circulation IssuesBlood ClotsBlood Pressure HighBlood Pressure LowBone InjuryConstipationChronic PainCancerDental IssuesDepressionDiabetes 1Diabetes 2DiarrheaDigestive IssuesFace InjuryFatigueFibromyalgiaFungal InfectionsHeadache/MigrainesHearingHerniaHeart ProblemsInfectious DiseaseJaw Pain/TMJMental Health DisordersMuscle Injury/PainNeurological IssuesNumbness/TinglingPregnancyRashesSinus ProblemsSleep DisorderSpinal DisordersSprains/StrainsStress/TensionVaricose VeinsVision ProblemsNoneOther
Please elaborate on anything that applied to you or list any conditions not listed
i.e. where is your arthritis, type of birth control, what bone did you injure, etc.
Do you smoke tobacco?*

YesNoOccasionally
Do you take prescription medications?*

YesNoOnly When Ill
Do you consume alcoholic beverages?*

YesNoOccasionally
Do you marijuana?*

YesNoOccasionally
Do you have a history of contagious diseases?*

YesNo
If Yes, What Type
Do you have a history of a serious physical Injury?*

YesNo
If Yes, What Type
Have you had any major surgeries?*

YesNo
If Yes, What Type
Have you ever had professional counseling?*

YesNo
Have you ever been diagnosed with a psychological disorder?*

YesNo
If Yes, What Type
As we cleanse our space regularly and occasionally use scents as a part of healing, are you bothered by or have any irritation to specific ones? (Sage, Palo Santo and Lavender are used regularly)*

YesNo
If yes, please specify
Do you follow any specific spiritual practice? If so, which one?*
Christian, Muslim, Pagan, etc.
Have you had any other experience with energy healing? If so, which one(s)?
i.e. crystal, reiki, sound
If you have had experience with energy healing, please share a little bit of your experience(s)
What is your primary purpose of your visit with Boudica Spirit?*
In general, how do you feel on a typical day that made you want to try crystal healing?*
How did you hear about Boudica Spirit?*

FacebookGoogleInstagramDirectoryPersonal ReferenceOther
If Personal Reference, who referred you?
Would you like to be contacted in the future (by email) about offers, promotions and events at Boudica Spirit?*

Yes! Please stay in touchNo thank you, not at this time
Always drink plenty of water after receiving an energy healing.

Please be aware that at Boudica Spirit (located in side the Edge Salon), we have both a shop dog and cat. If you have allergies to either or both, please take your allergy medications prior to coming to your appointment!
Please sign and date below to assert that the information is true to the best of your knowledge.

By signing below you are consenting that you understand that crystal healing is not meant to replace conventional medicine, but rather to complement and enhance it. You should always consult a medical professional when needed. By signing below, you hereby release the healer from any liability as a result of the services rendered (including intake and follow-ups).

To sign below using a PC, click and hold the right click button on the mouse. Using a cell phone or tablet, use the tip of your finger.
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