Blue Byrd Healing✿ Holistic Healing ✿

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Client Intake Form

Please complete all sections before your first session. Your information is kept confidential and emailed securely to Amber upon submission.

1. Client Information2. Medical History3. Medical Disclaimer4. Acknowledgement

Date*

Full Name*

Date of Birth*

Parent/Guardian (if minor)

Email*

Phone*

Best method of contact?

EmailTextCall

AMPMEither

Have you had a Reiki or Holistic Session before?

YesNo

How did you hear about Holistic Health?

Do you have a particular concern or focus for today?

Will you be comfortable lying on your back during the session?

YesNo

Are you sensitive to touch?

YesNo

Are you sensitive to sound?

YesNo

Are you sensitive to smells/fragrances/aromas?

YesNo

How much stress are you currently under? (1–10)5

How do you release your stress?

When stressed, where do you hold tension most?

How do you normally relieve this tension?

Does this help?

Reiki, CST and Reflexology is hands on therapy, unless otherwise requested.

Blue Byrd Healing

Holistic healing for mind, body, and nervous system wellness

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Contact

amberdawnnbyrd@gmail.com
214-552-5235
Nashville, Tennessee

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