Intake Form | My Site

First name

Last name

Birthday

Día

Mes

Año

Email

Phone

Address

Emergency Contact Name and Phone Number

What do you hope to gain from your session?

Is there anything physical, emotional, or energetic you would like me to be aware of before your session?

You may include current concers, how long they have been present, or anything else you feel is relevant.

Relevant surgeries, injuries, accidents, concussions/head injuries, or other significant events

How did you find ArteZen Vibrational Wellness? Referral / Google / Word-of-mouth / Instagram / Other

How would you describe your current stress level?

Low Stress

Moderate Stress

High Stress

Prefer not to say

Your Medical History

Allergies (drugs, chemicals, foods, airborne allergies, etc)

Current Medications and Supplements (if relevant to your session)

Please list any medications or supplements you feel may be relevant to your session

Are you currently pregnant or trying to become pregnant?

Yes

No

Anything you would like to share about your stress, sleep, self-care, or general well-being?

Anything else you would like me to know or discuss before your session?

Day-of Session Check-in

Caffeine, energy drinks, alcohol, recreational substances, lack of sleep, and other factors can temporarily affect nervous system responses. I may ask about anything recent that could be relevant to today's session.

Confirmation

I confirm that the information provided is accurate to the best of my knowledge. I will tell my practitioner if relevant information changes or if I experience discomfort during the session.

Please type your full name

Date

Enter today's date

Thank you for completing your intake form. I look forward to meeting you and discussing anything you would like to share before we begin your session. Please click Submit below to send your form.

Bienvenidos a ArteZen Vibrational Wellness

Johanne Pelletier
Practicante Certificado en Energía