Access Bars/Craniosacral/SomatoEmotional Release/Reiki | Client Intake Form

Please list any medical conditions your practitioner should be aware of

Please list any words, subjects, emotional triggers or boundaries your practitioner should be aware of

Please rate the following statements with 0 being "I really struggle with this" and 10 being "Yes, that's 100% me!"

I have lots of energy and stamina

I experience deep and restful sleeps consistently

My digestion has regular bowel movements and no pain/bloating

I am proud of my eating habits

I intentionally move my body with exercise more than 3x a week

I have my own hobbies that bring me joy

I am happy with my connection to God/Spirit

I have a daily meditation/prayer/gratitude practice

The thoughts I have towards my body are positive

I enjoy spending time in silence with myself

I am a trusting person

I have a strong community around me

I feel supported and encouraged by my romantic partner (if applicable)

I feel supported and encouraged by my parents (if applicable)

I feel valued in my relationships

I often worry about what people think of me

I feel confident expressing my needs/desires/wants

I feel proud of myself and my life

I spend too much time watching TV and/or surfing social media

I often feel lethargic and out of touch with life

I often feel like I don't belong and "want to go home"

I am excited about my future

Please list the physical symptoms (pain/illness/disorder, etc) you're looking to resolve

Please rate the physical pain

With 0 being "It's minor" and 10 being "It's unbearable"

Please list any emotional symptoms you're looking to resolve

Do any of these symptoms worsen with certain activities, environments, people, or circumstances? Please explain

Have you sought other professional assistance? Please list what has worked and what has not. Please list your experience seeking other practitioners.

At the end of 4 sessions working together, what would need to happen and how would you need to feel for you to know the time working together was 100% worth it? Please explain in detail

Session Expectations

Please know, the practitioner is not intended to act like a licensed therapists or counsellor.

You have control of the session and will never be pushed to release information you're uncomfortable with talking about.

Please know, the practitioner is not intended to act like a licensed therapists or counsellor.

A

I understand and agree.

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki session, it is perfectly normal to experience: A continued release of emotions.

Simply allow yourself to experience and observe the emotions that come up without judgement and especially without trying to change them. It's completely normal to feel angry, irritated, or "off" after this work. Don't worry! This is all part of the process. Remember: Emotions are your body and mind's way of communicating with you. Get curious about what's being communicated. With the subconscious mind, not only are certain emotions experienced, but we are also accessing different parts of your brain that have been "sleeping". This can be extremely exhausting. Honour that.

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki session, it is perfectly normal to experience: A continued release of emotions.

A

I understand the possible after effects.

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki session, it is perfectly normal to experience: Thirst.

Please make sure to drink lots of high-quality water after your Bars session to help release any toxins that your body is working hard to remove.

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki session, it is perfectly normal to experience: Thirst.

A

I understand the possible after effects.

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki | Client Intake Form session, it is perfectly normal to experience: Hunger.

You may experience intense hunger or strange cravings. This is completely normal. Your body worked hard to release the memories and emotions that were addressed in your session. Make sure to give it the fuel it requires. If you are craving salty or sweet, have a bit!

After an Access Bars/Craniosacral/SomatoEmotional Release/Reiki | Client Intake Form session, it is perfectly normal to experience: Hunger.

A

I understand the possible after effects.

Client Agreement

We appreciate the opportunity to discuss your current symptoms and concerns. We wish to make it clear that it is not our intention to diagnose, prescribe, or cure, but to offer recommendations and information to help you on your journey of transformation. If you require medical assistance, please consult a medical practitioner. Please do not make any adjustments to the prescribed medication without the approval of your doctor. If in doubt, please seek your GP's advice. In this session, the practitioner may discover the "root cause" of your current symptoms through conversation and processing. The root cause is often a hidden belief or decision you made due to a specific life event, experience, trauma, or influence. The practitioner may ask deeper questions to gain a better understanding of the event so they can effectively remove the impact it's had on your subconscious mind and in your current life.

Client Agreement

A

I understand and agree.

Signature

By signing below with your initials, you agree that the practitioner is not responsible or liable for any adverse side effects, nor are they guaranteeing immediate results. You're also stating that you have had the opportunity to ask questions, and agree to receive the modality of Access Bars/Craniosacral/SomatoEmotional Release/Reiki.

(Please sign below & date)

Signature