If you’re new here,please fill out the client intake form belowIf you’ve already previously filled out the form, click here. Name * First Name Last Name Email * What are your goals and intentions? * Do you have a trusted individual to support you in your healing journey? * Yes No Your Trusted Contact's Name * First Name Last Name Trusted Contact's Number * Trusted Contact's Email * What tools, practices and activities do you use to relieve stress and maintain your wellbeing? * Have you ever had a shamanic healing or craniosacral session? * What prompted you to book this session today? * Where in your body do you hold tension? * Are you pregnant? If so, when is your due date? MM DD YYYY *Allergies/sensitivity to latex, oils or scents? * Surgeries and/or Injuries (include approximate dates) Accidents, traumas and/or abuse you have experienced (include approximate dates) Medications you are currently taking and the conditions they are related to. Other health concerns, mental/medical conditions and phobias that you have. I understand that during this holistic healing session with Rebecka Wozniak I will receive insights + information for the purpose of relaxation, relief and reclamation of my body, mind and spirit. I further understand that this holistic approach should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a qualified medical specialist in regards to such inquiry. I understand that energy medicine practitioners are not qualified to diagnose or prescribe western medications. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. * Type in "I agree" if you have read the above disclaimer and agree to the terms. I agree to give 24-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 24-hour notice or do not show up to my appointment I agree to pay the full cost of the healing session. * Type in "I agree" if you have read the above disclaimer and agree to the terms. Thank you!
