Women’s Private Healing Intake Form

So that I can best serve you and ensure you get the most out of your experience during our time together, please fill out all questions on the intake form to the best of your knowledge. I look forward to sharing your journey.

Much love, Emma Beth

 
Personal Info
Name *
Name
Personal History
Have you ever received a sexual healing session of any kind? *
Do you have a history of abuse or trauma that you are aware of (of any kind: sexual, physical, emotional, etc)? *
Do you suspect hidden trauma in your history, including absorbed energies from transgenerational influences, past-life records and collective cultural sources ?
Have you been exposed to or diagnosed with any sexually transmitted infections? *
Are you pregnant? *
Do you expect to be menstruating during your session? *
Do you have any physical or mental limitations, injuries, or restrictions that might impact your session? *
Our Session
What to expect from your initial session: We will start with a period of discussion so that I can understand your needs and create a customized healing experience for you. During this time, I will share with you the options for proceeding with the session based on your needs as well as how you can get the most out of it. I will also answer any questions you have. We will be working on a massage table as we proceed into the main part of the session. As this part of the session comes to a close, there will be a period of integration and grounding to prepare you for re-entry into your life with a renewed perspective.
If you are unsure, please select 'Unsure' and I will make a time to contact you to discuss both options .in more detail.
Declaration
I understand that the session(s) I receive is/are provided for the purpose of healing, releasing, awakening, and reclaiming wholeness. If I experience any pain or discomfort during the session, I will immediately inform the practitioner. I further understand that the sessions(s) should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that my practitioner is not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my profile and understand that there shall be no liability on the practitioner’s part for any reason whatsoever.