CLIENT INTAKE FORM

Please complete the following before we start your session. Any information shared is for the purpose of conversation only, and will be kept in confidence.

Blue HeronName:

Email:

Phone:

Age :


Date of Birth:


Brief Description of Desired Outcome or Intention for Session

Please list any conditions, surgeries or medications that you feel I need to be aware of.



By Pressing Submit You Aknowledge This Client Agreement Below:
I agree to communicate with my practitioner. I understand that my practitioner does not treat or diagnose any condition or disease. I understand that energy work is not a substitute for medical care.

Questons, Comments:|
Please email me directly at dagnystjohn@gmail.com

All payment is due at the time of service. Cancellation notice required 48 hours prior to appointment or a “no show” fee will be applied.