Three Feathers Holistic Session Intake Form

Name: *

Email address: *

How did you hear of Three Feathers Holistic: Energy Healing & Wellness?

Motivation for booking this particular session? *

What would you like to release? *

What would you like to create in your life or expand in your life? *

Have you experienced any types of therapeutic healing sessions? If yes, what kind?

What is your current stress level? *

Our chakras, or energy centers, affect the way we think, feel, and handle our day to day lives. Depending on what is going on, we might find ourselves being triggered or shifting out of being in a good place. When we are feeling "off" there is energy that is blocked in our energy field and tracking where it is takes us to the emotional root. It is in this place that we can begin to clear the imprint and create growth in our lives.

With this in mind, have you been experiencing any of the following?

When we feel our best, the world feels beautiful and full of possibility. Think about what resonates with you when you connect with your true self.

Of the following choices, which describe a version of yourself that you would like to reconnect with or shift into?

Are you allergic to essential oils?

Yes

No

Prefer Not to Use Them

Are you allergic to smoke? ie: sage, palo santo

Yes

No

Prefer Not To Use Them

Are You Pregnant?

Yes

No

Do you have difficulty lying on your back for an extended amount of time?

Yes

No

Is there anything else you'd like to share with Tanya?

Cancellation policy: Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the Tanya’s day that could have been filled by another client. As such, she asks for a minimum of 24 hours notice for any cancellations or changes to your appointment. Tanya is fairly flexible and understands life happens but clients who fail to communicate in a timely manner and/or miss their appointment, will be charged. *

I have read the cancellation policy and agree

Each session is unique and specifically tailored to the individual. Energy healing sessions consist of discussion of session goals, time on the treatment table, and a few minutes at the end to discuss what came up and how to integrate the session. Each session is allotted a specific time and will be honored in that way.

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Three Feathers Holistic's services neither diagnose nor prescribe for disease conditions. All clients are encouraged to seek medical help when those services are deemed necessary. The client accepts total responsibility for his/her own health care and maintenance. Nothing said, typed, printed or produced by me is intended or meant to diagnose, prescribe, treat a disease, or take the place of a licensed physician. This work is not a medical treatment, and Tanya does not prescribe medications and/or substances. The Energy Healing Session given involves a natural method of energy balancing for the purpose of stress reduction, relaxation, and healing. I, Tanya Fuller, will not interfere with the treatment of a licensed medical professional. An Energy Healing Session is wonderful complementary avenue to help support you mental, emotional, and physical health goals.

Three Feathers Holistic agrees to: Provide Energy Healing to clients with respect for their dignity, individual needs and values without discrimination. Be without judgement concerning race, color, creed, gender or sexual orientation. Provide comprehensive and easy-to-understand information to allow clients to make informed choices. Respect the client’s right to choose his or her own forms and path of healing. Act honestly and maintain professional integrity. Practice only within the boundaries of the my competence/qualifications. Acknowledge and respect all practitioners and disciplines. Work to foster and maintain the trust of clients and the general public. Keep all client information confidential unless required by law to do otherwise. Comply with the Continuing Professional Development requirements of the Reiki Council/specific regulators Respond promptly and constructively to concerns, criticisms and complaints.

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Confidentiality: Everything that is discussed between the client and I, Tanya Fuller, is confidential and unique to the session. All information will be kept confidential with the Health Insurance Portability and Accountability Act (HIPAA) regulations.

And most important of all, this energy work is under the guidance of 100% Light & Love and to the Highest Good To All. Aho.

Signature: *

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Date * +

Heaviness/Sluggish	Bored	Materialism
Hoarding	Fearful	Restless
Spacey	Overly Emotional	Poor Boundaries
Obsessive Thoughts/Behaviors	Rigid	Numb
Cut Off From Pleasure	Controlling	Aggression
Scattered	Constantly moving/active	Weak Will
Poor Self-Esteem	Passive Aggressive	Sluggish
Afraid	Codependency	Poor Boundaries
Possessiveness	Jealousy	Shyness
Loneliness	Isolated	Bitter
Critical	Lack of Empathy	Excessive Talking/Spinning
Inability to Focus	Fear of Speaking Truth	Headaches
Nightmares	Difficulty Concentrating	Memory Problems
In Denial	Lack of Creativity	Over Thinking
Dissociation/Disconnection	Skepticism	Limited Beliefs
Apathy Apathy

Stable	Grounded	Physically fit
Prosperous	Trusting	Connected to Sexuality
In the Flow	Spontaneous	Strong Will
Feeling Full of Purpose	Healthy Self Esteem	Balanced
Compassionate	Nurturing	Self-loving
Self-acceptance	Clear Communicator	Creative
Aligned	Intuitive	Imaginative
Wise	Spiritually Connected Spiritually Connected