Intake Form | Soul Bloom

First name

Last name

Phone

Email

Preferred Pronouns

What Brings You Here Today?

In your own words, what are you hoping to receive from your session?

Please check the boxes below that pertain to your physical health history:

Currently have diagnosed medical conditions

Under the care of a physician, therapist, or mental health professional

Have had recent surgeries or injuries

Are pregnant or trying to conceive

Currently taking medications that are relevant to bodywork safety

Have areas of chronic pain or tension

Please explain if you checked boxes 1, 3, 5, or 6.

Emotional & Nervous System Check-In. On a Scale of 1-10, Rate your Stress level:

On a Scale of 1-10, Rate Your Energy level:

On a Scale of 1-10, Rate Your Sleep Quality:

On a Scale of 1-10, Rate Your Emotional Stability:

Spiritual & Energetic Background:

Is there anything you would NOT want included?

Consent & Understanding.

I understand these services are holistic and not a substitute for medical or psychological treatment.

I understand intuitive guidance is for spiritual insight and personal growth.

I consent to touch-based therapy if applicable.

I may stop the session at any time.

Signature

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Date

Month

Day

Year

Intake Form: