Boudica Spirit Client Intake Form
Crystal Healing and Gua Sha Facial
Name-First & Last
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Address
*
Street Address
Apartment /Lot #, Suite, Other
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Email Address:
*
example@example.com
Date of Birth:
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/
Month
/
Day
Year
Date
Preferred Gender Pronouns (Mark Your Preference):
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She/Her
He/Him
They/Theirs
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Marital Status
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Single
Married
Divorced
Widow/Widower
Occupation:
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Emergency Contact Name
*
Relation to emergency contact
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Emergency Contact Phone Number
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Area Code
Phone Number
What attracted you to crystal healing?
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Please mark all that apply to you
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Abdominal/Digestive Problems
Acne/Skin Disorders
Allergies
Arthritis/Tendonitis
Asthma/Lung Conditios
Back/Neck Pain
Birth Control/IUD
Blood Clots
Blook Pressure (High or Low)
Constipation/Diarrhea
Cronic Pain
Cancer/Tumors
Dental Issues
Depression
Diabetes
Fatigue
Fibromyalgia
Headaches/Migraines
Hearing Problems
Hernia
Heart/Circulatory Problems
Infectious Illness
Injuries to Face/Neck
Jaw Pain/TMJ Issues
Mental Health Disorders
Muscle/Bone Injuries
Muscle/Joint Pain
Neurological Issues
Numbness/Tingling
Pregnancy
Rash/Fungal Infection
Sinus Problems
Sleep Difficulties
Spinal Disorders
Sprains/Strains
Tension/Stress
Varicose Veins
None
Vision Problems, Glasses/Contacts
Other
Other conditions not listed above or more information on issues above
0/1000
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Do you smoke?
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Yes
No
Casualy (at parties or while drinking)
Do you take any prescribed medications?
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Yes
No
Only when Ill
Do you consume alcoholic beverages?
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Yes
No
Ocasionally
Do you have a history of contagious disease(s)?
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Yes
No
More Info
Do you have a history of serious physical injury?
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Yes
No
More Info
Have you had any surgeries or hospitalizations?
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Yes
No
More Info
Have you ever been diagnosed with a psychological disorder?
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Yes
No
More Info
Have you had any professional counseling or therapy?
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Yes
No
More Info
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A lot of Sage, Palo Santo and other herbs are burned as a way of cleansing the healing room. Are you bothered by or have an irritation by any scents?
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Yes
No
If Yes, please list the scents that you are bothered by (if all, type all)
Do You Follow Any Spiritual Practice? If so, what?
Have you had any prior experience with Crystal Healing?
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Yes
No
Lots
If you have worked with crystals in the past, please share a little bit about your overall experience here:
What's the Purpose of Your Visit Today?
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Please mark any areas where you feel discomfort
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What is your skin type?
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Dry
Normal
Oily
Combination
Which facial lines do you have?
Brow
Cheeks
Eyes (Crow's Feet)
Forehead
Smile
Lip
Other
Do you have sensitive skin?
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Yes
No
Other
Do you have any of the following to your face, jaw, sides of neck or back of neck?
Pain
Soreness
Swelling
Other
If you have any pain, soreness or swelling, please elaborate.
Are you bothered by or allergic to any of the following oils? Select all that apply
Blue Tansy
Cedarwood
Chamomile
Coconut
Copaiba
Grapefruit
Juniper Berry
Melissa
Rosehip
Sweet Almond
Please add any essential oils that you have an allergy nor irritation to.
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In general, how are you feeling today (i.e. I'm tired from grocery shopping and my children were a handful this morning, or, I am skeptical about this session but am willing to give it a try)?
*
0/1000
Would you like to be contacted by email about future crystal healing promotions and offers?
*
Yes! Please stay in touch.
No thank you. Not at this time.
How did you hear about us (mark all that apply)?
*
Facebook
Search Engine
Directory/Yellow Pages
Instagram
Personal Reference
Other
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).
Today's Date
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Month
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Day
Year
Date
Client Signature
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