Holistic Intake Form

Thank you for taking a few moments to complete this form.

Your answers help me understand your needs and create a session that feels safe, supportive and attuned to you.

All information shared here remains confidential.

Emergency Contact Number:

Emergency Contact Name:

How did you hear about my work?

Instagram

Recommendation from a friend

Previous session with me

Therapist / practitioner referral

What does your body or mind need most right now?

Deep relaxation

Nervous system regulation

Grounding and feeling more centred

Rest and slowing down

Reconnecting with myself

Releasing physical tension

Better sleep and inner calm

Clarity and mental space

Simply time for myself

I’m not sure yet, I’m just curious

Something else (please share below)

What would you most like to receive from this session?

How have you been feeling lately?

calm

emotionally sensitive

disconnected from body

feeling good but wanting deeper connection

Do you currently have or have you ever experienced?

heart conditions

blood clotting issues

mental health diagnosis

Please provide details if applicable or add any other conditions non mentioned above:

I understand that if I have a medical condition or I am pregnant, I may be required to provide approval from a qualified healthcare professional before the session.

I agree

Are you currently taking medication?

Yes

If yes please specify:

Have you experienced any of the following before?

sound healing

movement practice (yoga, qigong, dance)

other creative or expressive practices

If yes please specify:

What would help you feel safe and comfortable?

silence

Touch preferences (for bodywork):

I am comfortable with therapeutic touch

I prefer minimal touch

I am not comfortable with touch

If yes please specify a pressure

Do you have any allergies or sensitivities I should be aware of?

food

skin sensitivity (oils, essential oils, products used on the skin)

strong scents / fragrances

If yes, please specify:

Do you have your preference ?

Sound Immersion Experience

Deep Rest Experience

Grounded Within Experience

Somatic Bodywork Experience

PeLoHa Massage Ceremony

Which session length are you interested in?

60 min

Not sure – I’d like guidance

Is there anything important I should know to support you safely during the session?
(e.g. trauma history, triggers, sensitivities)

Is there anything that would make this session feel especially supportive or meaningful for you?

Please confirm

I understand this work is not a substitute for medical or psychological treatment.

I will inform the practitioner about any health changes.

I take responsibility for communicating discomfort during the session

Holistic Session Consent

I understand that the sessions offered may include a combination of holistic practices, which may involve sound, bodywork, energy-based approaches, movement, breath, voice work, creative expression or other supportive wellbeing techniques.

These sessions are designed to support relaxation, nervous system regulation, self-awareness and overall wellbeing, but they are not a substitute for medical or psychological treatment.

The specific modalities used during the session may be discussed and agreed upon during a consultation or determined intuitively during the session, depending on the client's needs.

I acknowledge that:

the practitioner may intuitively combine different modalities depending on what feels appropriate for the session

I am free to decline any technique at any time

I will communicate any discomfort or concerns during the session

I give my informed consent to participate in these holistic wellbeing experiences.

To confirm your session, a 50% deposit is required within 24 hours of booking.

I agree

Cancellation Policy

Please confirm you understand:

Sessions can be rescheduled with a minimum of 48 hours’ notice.

Deposits and payments are non-refundable.

If you reschedule within this time, your payment can be transferred to a new session.

Cancellations made less than 48 hours before the session will result in loss of the deposit.

No-shows or same-day cancellations are non-refundable and non-transferable.

Untitled checkboxes field

I agree

The practitioner reserves the right to refuse or discontinue a session if it is not appropriate for the client’s wellbeing.

I agree

I consent to the storage of my personal data for.

booking and session records

follow-up communication

I understand that this form must be completed at least 24 hours before my session.

I agree

Holistic Intake Form

Full Name:

Email:

Phone number:

Date of Birth:

City/Post Code:

Emergency Contact Number:

Emergency Contact Name:

How did you hear about my work?

Please specify:

What does your body or mind need most right now?

What would you most like to receive from this session?

How have you been feeling lately?

Do you currently have or have you ever experienced?

Please provide details if applicable or add any other conditions non mentioned above:

I understand that if I have a medical condition or I am pregnant, I may be required to provide approval from a qualified healthcare professional before the session.

Are you currently taking medication?

If yes please specify:

Have you experienced any of the following before?

If yes please specify:

What would help you feel safe and comfortable?

Please specify:

Touch preferences (for bodywork):

If yes please specify a pressure

Do you have any allergies or sensitivities I should be aware of?

If yes, please specify:

Do you have your preference ?

Which session length are you interested in?

Is there anything important I should know to support you safely during the session?
(e.g. trauma history, triggers, sensitivities)

Is there anything that would make this session feel especially supportive or meaningful for you?

Please confirm

I acknowledge that:

To confirm your session, a 50% deposit is required within 24 hours of booking.

The practitioner reserves the right to refuse or discontinue a session if it is not appropriate for the client’s wellbeing.

I consent to the storage of my personal data for.

I understand that this form must be completed at least 24 hours before my session.

Date:

Signature:

Holistic Intake Form

Full Name:

Email:

Phone number:

Date of Birth:

City/Post Code:

Emergency Contact Number:

Emergency Contact Name:

How did you hear about my work?

Please specify:

What does your body or mind need most right now?

What would you most like to receive from this session?

How have you been feeling lately?

Do you currently have or have you ever experienced?

Please provide details if applicable or add any other conditions non mentioned above:

I understand that if I have a medical condition or I am pregnant, I may be required to provide approval from a qualified healthcare professional before the session.

Are you currently taking medication?

If yes please specify:

Have you experienced any of the following before?

If yes please specify:

What would help you feel safe and comfortable?

Please specify:

Touch preferences (for bodywork):

If yes please specify a pressure

Do you have any allergies or sensitivities I should be aware of?

If yes, please specify:

Do you have your preference ?

Which session length are you interested in?

Is there anything important I should know to support you safely during the session?(e.g. trauma history, triggers, sensitivities)

Is there anything that would make this session feel especially supportive or meaningful for you?

Please confirm

I acknowledge that:

To confirm your session, a 50% deposit is required within 24 hours of booking.

The practitioner reserves the right to refuse or discontinue a session if it is not appropriate for the client’s wellbeing.

I consent to the storage of my personal data for.

I understand that this form must be completed at least 24 hours before my session.

Date:

Signature:

Is there anything important I should know to support you safely during the session?
(e.g. trauma history, triggers, sensitivities)