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Foot Zone & Emotion Code Client Intake

Name

Email

Date of Birth

Would you prefer to be resting during your Foot Zone, or is it okay to receive it while going about your day as usual?

Would you prefer to be resting during your Foot Zone, or is it okay to receive it while going about your day as usual?

Are there any days and/or times that you would prefer NOT to receive your foot zone?

What brings you to this session? Are you experiencing any physical, mental, emotional, spiritual, or energetic imbalances that you would like to focus on?

On a scale of 1-10, how intense does this issue feel right now? 1 = Barely noticeable, 10 = Overwhelming

On a scale of 1-10, how intense does this issue feel right now? 1 = Barely noticeable, 10 = Overwhelming

Have you ever received a Foot Zone (in-person or distance) before?

Have you ever received a Foot Zone (in-person or distance) before?

Have you ever received an Emotion Code session or any other energy healing before? If yes, please provide a brief description of your experience.

How would you describe your current energy levels?

How would you describe your current physical health?

Are there any current life events or stressors that you are currently navigating?

What are your top 1-2 intentions for this Foot Zone & Emotion Code Session?

Do you have any medical conditions, pregnancy, sensitivities, or anything else I need to be aware of while completing your Foot Zone & Emotion Code Session?

Do you experience any adverse reactions to magnets?

Do you experience any adverse reactions to magnets?

Agreement & Consent

I acknowledge that the Foot Zone & Emotion Code session I have purchased is a holistic wellness service intended to support my emotional, mental, physical, spiritual, and energetic well-being. I understand this service is not a substitute for medical advice, diagnosis, or treatment and that Amanda of Holistic Harmony does not claim to diagnose, cure, or treat any medical condition.
I agree to take full responsibility for my own health and wellness decisions. I understand that results vary from person to person and are not guaranteed. All sales are final and non-refundable.
I also understand that all content provided is the intellectual property of Holistic Harmony and may not be shared or reproduced without permission.
Agreement & Consent

Is there anything else you would like to share with me before your Distance Foot Zone & Emotion Code session?