Remote Healing Intake Form

1. Basic Information

Name

Preferred pronouns (optional)

Email

Phone (optional)

Time zone

How did you find me? (optional)

2. What’s Bringing You Here Now

(You can answer briefly or in detail — whatever feels right.)

What inspired you to reach out for healing support at this time?

Is there a particular situation, pattern, or transition you're navigating right now?

What are you hoping to receive or experience through our work together?

3. Emotional & Inner Landscape

These questions are here to help me understand your inner world. There are no right or wrong answers.

How would you describe your emotional state over the past few weeks?

Mostly steadyTender / sensitiveAnxious / overwhelmedLow / heavyIn transitionOther

If Other, please describe:

Are there emotions that feel especially present or difficult to move right now?

Are you currently working with a therapist, counselor, or mental health professional?

YesNoPrefer not to say

Is there anything about your emotional or mental health that you'd like me to be aware of?

4. Physical Body Awareness

You do not need to share medical details unless you want to. This is about how your body feels to you.

How does your body generally feel these days?

Relaxed / regulatedTired / depletedTense / bracedIn pain or discomfortVariable / hard to tell

Are there specific areas of your body that are asking for attention?

Do you live with any chronic conditions, injuries, or sensitivities that feel relevant to our work together?

Are you currently under medical care for anything you feel I should know about? (Optional)

5. Nervous System & Capacity

These questions help me pace sessions in a way that supports safety and integration.

When you feel stressed or overwhelmed, what tends to help you regulate or come back to yourself?

What tends to make things harder when you’re already stretched?

How do you usually feel after emotional or energetic work?

Grounded and calmOpen but tiredActivated / sensitiveIt varies

6. Prior Healing Experience (If Any)

Have you worked with energy healing, somatic work, body-based practices, or spiritual support before?

What felt supportive about those experiences?

Was there anything that didn’t feel helpful or that you’d prefer to avoid?

7. Intentions & Boundaries

What does feeling “supported” look like to you?

Are there areas of your life or topics you are not ready to explore right now?

Is there anything you want me to go slowly with or check in about during sessions?

8. Aftercare & Integration Preferences

After a session, what kind of support feels best?

Quiet restJournaling or reflectionGentle movementPractical grounding suggestionsMinimal guidance — I prefer to integrate on my own

Would you like brief integration suggestions after sessions?

YesNoSometimes

9. Consent & Acknowledgement

Please read and check the statements below:

I understand that remote healing is a supportive, complementary practice and is not a substitute for medical or mental health care.
I understand that I am responsible for my own wellbeing and can pause or stop a session at any time.
I consent to receiving remote healing sessions.

Signature (typed)

Date

Thank you for your trust. I look forward to working together in a way that honors your pace, autonomy, and wholeness.