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Healers
Retreats
Healing Services
Events
Intake Form
Intake Form
First name
*
Last name
*
Email
*
Phone
Birthday
Month
Day
Year
Emergency Contact Name + Number
1. What inspired you to say “yes” to this journey?
2. Have you ever worked with a guide, therapist, or healing practitioner before?
Yes
No
If yes, briefly describe your experience:
3. Have you ever done breathwork, meditation, energy work, plant medicine, or any other healing modalities?
Yes
No
If yes, what modalities have you explored and what was your experience like?
4. What are you currently moving through in life emotionally, mentally, physically, or spiritually?
5. What are the top 2–3 challenges or patterns you want to shift during this container?
6. What’s one area of your life where you feel stuck or out of alignment?
7. What are you truly seeking at this point in your journey (inner peace, clarity, purpose, confidence, self-love, etc.)?
8. If this journey supported you beyond your expectations, what would be different in your life a few months from now?
9. What’s your intention for this container?
10. Are you currently taking any medications or receiving any medical or psychological care?
Yes
No
If yes, please list:
11. What are your current daily or weekly self-care practices (if any)?
12. How much time are you realistically able and willing to commit to your healing and self-care each week? (e.g., time for sessions, integration, reflection, practices, etc.)
13. Do you have a support system or safe relationships in your life you can lean on during this journey?
14. Is there anything else you’d like to share before we begin?
Submit
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