Personalized Energy Healing Intake Form

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Your Information - Step 1 of 2

Name

First

Last

Age

What are your primary concerns or goals for this healing session?

Are you currently experiencing any physical or emotional symptoms you’d like addressed?

Do you have any specific areas of the body or energy system (e.g., chakras, aura) you feel need attention?

Have you experienced energy healing or similar practices before? (Yes/No) If yes, please briefly describe your experience.

Have you experienced energy healing or similar practices before?

body you’d

Are there any specific emotions, patterns, or memories you feel may be contributing to your current challenges?

Any additional information you’d like to share to help guide this session?

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