CRYSTAL BODYWORK CLIENT INTAKE FORM

THE WITCH'S WEAVE CRYSTAL BODYWORK

CLIENT INTAKE FORM

First name

Last name

Phone

Emergency Contact: Name/Phone Number

Do you have any physical restrictions or injury including ankle/knee/hip/neck/ shoulder injury or pain?

Do you have any health or wellness concerns I should be aware of?

Please check off if you have any of the following:

any allergies to oils, incense, or fabrics

sensitive to fragrances from essential oils or incense

are pregnant

have any food related allergies

None of the above

If you check off any boxes above, please elaborate.

Have you received any type of energy healing before?

What is your age range?

10-20

21-39

40-59

60+

YOUR INFRADIAN RHYTHM: a 28-31 day cycle that regulates the menstrual cycle. ARE YOU AWARE OF WHICH PART OF YOUR MOON CYCLE YOU ARE IN AT THE TIME OF YOUR SERVICE? (this will allow me to prepare your herbal blends to support what your body is needing)

MENSTRUATION (days 1 - 5 of your period)

FOLLICULAR (days 6-12 after the first day of your period)

OVULATORY (days 13-17 after the first day of your period)

LUTEAL (days 18-28+ after the first day of your period)

NO LONGER (historectomy / menopause / pregnant/ other)

What are you hoping to acheive from THE WITCHE'S WEAVE CRYSTAL BODYWORK RITUAL SESSION? (physically, emotionally, spiritually or other)

Do you feel any energy stuck or any stagnation in your body?If yes, where are you feeling them?

Is there anything you would like to call in or let go of on a spiritual level?

How would you describe your current stress levels? Low / Meduim / High

How did your hear about Northern Alkemi?

Client Acknowledgement: YOUR SATISFACTION AND SAFETY IS MY NUMBER ONE PRIORITY TO ENSURE YOUR WELLBEING BEFORE, DURING AND AFTER YOUR TREATMENT. PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND CHECK MARK BELOW:

I have agreed to receive crystal healing energy therapies from Charmaine Holan, of Northern Alkemi.

I understand that my healing sessions will involve gentle energy techniques including: the placement of small crystals, gemstones and tuning forks on my body, guided meditation, and light touch.

I understand that crystal healing can assist in stress reduction, relaxation, and wellness, but is not intended to replace proper diagnostic/medical/clinical/psychological care.

I understand that I should seek assistance from a licensed medical professional for any serious psychological/physical/emotional ailment that I have.

I understand that my treatment is conducted on a private property (158 Sonora Crescent, Fort Saskatchewan), and that all reasonable efforts have been made to ensure it is safe and comfortable for my attendance.

I accept full liability in the very unlikely event of my personal injury while on the above mentioned premises. I also accept full responsibility and liability for any event that may occur because of my personal choices or actions undertaken as a result of my healing session.

I’ve shared all relevant details about my health history, including any medications I’m currently taking and any past reactions to products or medications that might affect or interfere with this treatment.

By proceeding, you confirm that you fully understand the service you’ve requested and the associated risks. You’ve shared any relevant pre-existing conditions, allergies, or sensitivities with your service provider. Northern Alkemi and the service provider are not responsible for any dissatisfaction, discomfort, injury, or damage that may occur as a result of the service.

Date

Year

Month

Day

Signature

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