Intuitive Healing Intake Form | my.schoolofintuitivestudies.com

Name*

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Email*

Phone*

Birthdate*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Best contact method and time to reach you:*

What is your occupation? If employed, how long?*

Are you under the care of a physician?*

Do you have a past history of illness/surgery? Are you currently taking any medications?*

Any sensitivity to touch, smells, language?*

Do you have a particular concern?*

Do you have past experience with holistic modalities?*

Addictions*

Please indicate any applicable. Keep in mind that addiction is simply a pattern we repeat. Anything can be an addiction when you do it repeatedly, even when it doesn't serve you.

Other:

Mental Addictions*

Other:

STATEMENT OF ACKNOWLEDGEMENT AND RELEASE

- No information about you will be discussed or shared by me (Saori Murphy). Your information and our sessions are strictly confidential.

- Understand that I (Saori Murphy) am not acting as a licensed health practitioner. I am not diagnosing, prescribing or preforming medical treatment during our sessions.

- Our sessions together do not take the place of medical care, and you understand that I recommend you see a licensed physician or health care professional for any physical or psychological ailments you may have.

- You have come to me of your own free will for spiritual services and have not come for medical advice.

- My services are consultative in nature and that decisions made and actions taken, based on input or advice from me are ultimately your responsibility. I make no guaranties, warranties or claims, expressed or implied.

- A 24 hour notice is required for cancellation. Please contact either me or the School of Intuitive Studies to cancel your session. A cancellation fee of half the session will be charged for missed sessions or cancellations not made 24 hours prior to the session.

I agree

I understand and agree to the statement above & cancellation policy. **

Enter your name in agreement.

I understand and agree to the statement above & cancellation policy.*

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