Shamanic Healing Intake Form 🌿 New Client Intake Form For Shamanic Healing & Soul Work All information shared is held in sacred confidentiality. 1. Personal Information Full Name Preferred Name / Pronouns (if any) Date of Birth Phone Number Email Address Emergency Contact Name & Number Location (City, State, Country) 2. Spiritual & Energetic History Please share from the heart. There are no right or wrong answers—only what is true for you in this moment. Have you received shamanic healing or energy work before? Yes No If yes, please describe your experience: What draws you to this healing work at this time in your life? Are you currently on a spiritual or healing journey? If so, how would you describe where you are right now? Do you feel a connection with Spirit/Source/Guides/Ancestors/Nature? Yes No Unsure If yes, please share a little about your relationship: 3. Physical, Emotional & Mental Well-being Any current or past physical conditions, injuries, or surgeries? Are you currently under the care of a doctor, therapist, or counselor? Yes No If yes, please explain: Are you currently taking medications or supplements? Yes No If yes, please list them and their intended purpose: Are there emotional or mental health concerns you are currently navigating? Yes No If yes, please share as you feel comfortable: 4. Intentions for Healing What are you seeking support with? Emotional healing Trauma release Ancestral healing Spiritual connection Soul retrieval Energy clearing Guidance / life direction Ceremony / ritual support Other: What is your deepest intention for this healing work? 5. Consent & Agreement By signing below, I acknowledge that: I am voluntarily engaging in spiritual healing work, which may include energy healing, journeying, or guided ceremony. I understand this work is not a substitute for medical or psychological care, and the practitioner does not diagnose or prescribe. I take full responsibility for my healing journey, knowing that true transformation arises from within. All personal information will be held in sacred confidence, with integrity and respect. Signature Date 6. Anything Else You’d Like to Share With Me? Use this space to speak from your soul—anything you’d like me to know, hold, or be aware of as we enter sacred space together. Submit
