Please fill out to the best of your knowledge, and put N/A if necessary. All information shared is designed to help your practitioner help you. All information will be held in confidence. Thank you!

Your Name:

Age at time of intake:

Email Address:

Phone:

Emergency Contact Name:

Emergency Contact Phone:

What services are you seeking? (check all that apply)

Why are you seeking this service(s) at this time?

Do you have any injuries, pain or other physical health issues of concern?

How is your mental health, stress levels, and mood?

Right now: (In general)

Do you practice self-care? If so, how?

Is there a stress or trauma (old or new) you are wanting to access/work through or release?

What (if any) boundaries do you wish to share/uphold? (Boundaries may relate to physical injuries or emotional wounds, traumas or triggers related to words or touch, etc)

What is your intention for your session / our work together?

Other information you would like to share that will inform the session:

Would you be willing to provide feedback or a testimonial (by name or anonymously) following our work together?

Yes No

Thank you for sharing honestly and openly. All information shared is kept confidential. I look forward to our session(s)!

I am a channel for healing energy to support my clients in moving stuck emotions and energetic blocks that prevent them from healing, receiving love, and living as the truest, most joyful version of themselves.

I Provide

Chakra balancing and meditation
Yoga asana practice, with the intention to shift or move stagnant energy
Reiki sessions
Healing touch
Coaching Session
Tantric healing sessions

Book a Free Consultation

Book a Session

Please complete the form below to book a complimentary 30 minute consultation.

First Name

Last Name

Phone Number

What do you hope to get out of your session?

Would you like to speak with Vanessa prior to booking a session?

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Best days & times to meet: