Appointment Intake Form

This is a private form to gather typical information before our session. Please complete it at least four hours before we meet. Until then, I’ll look forward to meeting with you and will hold you and our work together in mind and spirit.

Name

First Name

Last Name

Appointment Date

YYYY

Appointment Time

Hour

Minute

Second

Emergency Contact + Phone Number

Medical conditions I should know about:

What pronouns should I use to address you?

How did you hear about Sparkle Circle Healing?

What will we be working on during our session?

Are you sensitive to touch?

May I sign you up for very periodic emails?

I am not a doctor and of course am obligated to say that I make no guarantees or claims for the resolution of physical, mental, or emotional issues. Please consult your doctor for any treatment plans. My work is solely spiritual and energetic in nature.