Intake Form | Connie 1

First name

Last name

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Contact Preferences

Phone call

Email

Text

Emergency Contact Name

Emergency Contact Phone

Main reasons for seeking holistic practices?

Describe your overall health journey.

Are you currently under the care of a healthcare professional?

Yes

No

If yes, please specify:

Do you have any diagnosed medical conditions or health concerns?

Are you currently taking any medications or supplements?

Yes

No

If yes, please list:

Do you have any allergies or sensitivities?

Yes

No

If yes, please list:

Have you ever experienced energy healing modalities such as Reiki, meditation, or similar practices?

Yes

No

Stress and Mental Health

Physical Health

Emotional Wellbeing

Lifestyle and Habits

Difficulty balancing work and life

Poor eating habits or irregular meals

Lack of regular exercise

Spending too much time on screens/devices

Feeling unfulfilled or lacking purpose

Holistic and Energetic Well-being

Feeling stuck or stagnant in life

Difficulty relaxing or calming the mind

Trouble staying grounded or present

A sense of imbalance or disharmony

Feeling a lack of connection to self or higher purpose

What is your daily stress level on a scale of 1-10 (1=low, 10=high)

How often do you engage in self-care or wellness activities (exercise, meditation, hobbies)

Regularly

Sometimes

Rarely

Never

Do you have a spiritual practice or belief system that supports your wellness journey?

Yes

No

If yes, please describe

Describe your wellness goals or intentions

I understand that the services provided by Energy Wellness Studio are intended to support overall well-being and are not a substitute for medical or psychological treatment. The practitioner is not a licensed physician and does not diagnose, treat, or prescribe for any medical condition. By signing below, I consent to receive holistic

energy services and agree to communicate any concerns or changes in my health status that may impact the sessions.

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Date

Month

Day

Year

Energy Wellness Studio Intake Form