Page 1 of 1

Foot Zone Client Intake

Name

Email

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?

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

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

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 Session?

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

Agreement & Consent

I acknowledge that this session is a complementary wellness service and does not replace medical care. I understand that results can vary and that Amanda does not diagnose or treat medical conditions. I agree to participate voluntarily and release Holistic Harmony from liability.
Agreement & Consent

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