New Spiritual Services Client - Intake Form

First name

Last name

Date of Birth

Day

Month

Year

Phone

Address

Please enter your full address, including suburb and postcode.

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Medical Conditions and Allergies

Current Medications

Do you have a particular area of concern or you would like to focus on?

Is there anything else we need to be aware of?

I understand that Reiki, Spiritual Healing and Readings are gentle modalities, which sometimes includes gentle hands-on touch.

I understand that the practitioner does not diagnose conditions nor do they prescribe medical treatment of any kind. I understand that Spiritual Services does not take the place of medical care.

I understand that it is recommended that I seek advice from a medical professional for any physical or psychological ailment I may have.

I understand the Spiritual Services will not interfere with existing medical care and may complement any medical or psychological care I am receiving

Signature

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Peta Henderson

New Spiritual Services Client - Intake Form

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