Shamanic healing intake form

New clients: Please complete this form at least 24 hours before we meet. You’ll receive an email copy of your submissions.

Thank you!

Name *

First

Last

Preferred pronouns

(For example: he/him/his, she/her/hers, they/their/theirs)

Email *

Cell phone number *

Alternate phone number

For example, home or work number

Okay to leave messages?

Please check all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact's name *

First

Last

Contact number *

Relationship to you *