new patient intake form:self-love and spiritual wellness client with: Briana aniysa 𓍯𓂃𓏧♡ download pdf Name * First Name Last Name Email * Phone number (###) ### #### date of birth * MM DD YYYY preferred method of contact text email emergency contact First Name Last Name Phone (###) ### #### relationship have you ever worked with a holistic healer before? * yes no Do you currently have a medical diagnosis or condition you’d like me to be aware of? * yes no if yes: list any health conditions below Do you have any allergies or sensitivities (scents, oils, crystals, etc.)? yes no if yes: list below what brings you to the self- love & spiritual wellness clinic today? emotional healing stress relief energy cleansing/reiki chakra alignment spiritual mentorship other what goals and intentions do you have for your healing journey? * rate your current level of self-love, spiritual wellness, & inner peace * i love myself Strongly Disagree Disagree Neutral Agree Strongly Agree i feel happy within Strongly Disagree Disagree Neutral Agree Strongly Agree i feel confident in my spiritual journey Strongly Disagree Disagree Neutral Agree Strongly Agree I understand that Briana Aniysa is a Spiritual Wellness Practitioner and Reiki Master, not a medical doctor. Healing services are complementary and do not replace medical care. I take full responsibility for my own health and wellbeing. * enter first & last name to consent and agree Date MM DD YYYY Thank you! You will be contacted shortly.