Client Intake Form

Welcome to a deeper understanding and collaboration with your Heart, Spirit, and Soul. I look forward to connecting with you. Please use this form to give some information so I can respond to your needs specifically and get you set up with an appointment.

NOTE: If you have filled out this form before, you don’t need to fill it out again.

First Name

Last Name

Date

Introduction

Relationship Background

Date of Birth

If you are under 18, you need to have a parent or guardian fill out this form.

Time zone

Best way to connect with you

Skype ID

Phone

Are You filling our the form for someone else

Your Name

It is important to understand that the nature of our work together will be spiritual, emotional and supportive. All forms of work will be done with your direct permission and understanding. I work with the highest professional ethical standards and everything is strictly confidential. The work is meant to be empowering and bring wellbeing into your life. None of the work we do should replace or override you consulting with professional, licensed medical or other professionals. Your free will participation in the work is key to its success and the only way I will work with you. If you understand and agree please move on to a wee bit of legal understanding...except in the case of gross negligence or malpractice

Acceptance

I or my representative(s) agree to fully release and hold harmless Eileen Crispell and A Heart's Journey against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). Please read and review our Terms and Conditions and Privacy Policy.

Client Intake Form

THANK YOU!

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