New Client Intake FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneDOBHave you experienced Reiki, hypnosis, or energy healing before?YesNoWhat are your top 1–3 intentions or goals for this session?On a scale from 1–10, how stressed or anxious do you feel on a daily basis?Are you currently under the care of a healthcare provider for any physical or mental health conditions? (If yes, please specify if comfortable)Do you take any medications or supplements regularly? (Especially mood-altering, sleep, or pain-related meds)Do you have a history of trauma, PTSD, seizures, or dissociative episodes? (This is important for safely guiding hypnosis)Are you currently pregnant or trying to conceive? (So sessions can be safely tailored)(for Reiki clients) Do you prefer a more:Silent SessionVerbally guided sessionIntuitive mix of bothAre there any scents, music, or touch (during Reiki) you are sensitive to or would like to avoid?I understand Reiki and hypnosis are complementary and not a substitute for medical or psychological treatment. I give permission to receive these services and affirm that I’m doing so voluntarily. I understand all shared information is confidential unless required by law. *I agreeIs there anything else you’d like to share before we begin?Would you like to receive updates, offers, or inspiration from Angelic Touch Wellness by email?YesNoThe Following are Hypnosis Specific QuestionsWhat issue or behavior would you most like to work on through hypnosis? (e.g., anxiety, confidence, smoking, sleep, fears, past trauma, inner child work, etc.) sleep, Are Do How long has this issue been present in your life?Have you tried any other approaches to resolve this?(Therapy, medications, energy work, self-help, etc.)If this issue were resolved, how would your life change?Are there any fears, doubts, or hesitations you have about being hypnotized?Do you ever "zone out" while driving, watching TV, or reading — to the point where you lose track of time?YesNoSometimes(This is a natural trance and shows suggestibility)Do you have a strong inner critic or racing thoughts that get in the way of stillness?Yes, very muchSometimesNo, not reallyDo you have a diagnosed mental health condition (e.g., bipolar, schizophrenia, severe depression)?(This helps ensure hypnosis is appropriate)Do you have a history of panic attacks, flashbacks, or dissociation?(Important for regression and deep trance work)Are there any emotionally intense memories, traumas, or unresolved experiences you’re aware of that may surface during hypnosis?Is there anything you absolutely do NOT want to explore during hypnosis?Deposit *Price: $35.00Total$0.00Square *CardName on CardSubmit
