NEW CLIENT FORM

This form MUST be completed BEFORE we meet for our first session.

Information provided is protected as confidential and is collated and stored accordingly. By submitting this form, you are attesting that all information provided is correct.

First Name *

Last Name *

Email *

Please check this box to accept the disclaimer that Shadow Work is NOT intended to replace professional legal, medical, psychological, psychiatric and/or financial counsel. How you choose to act on this information is up to your own free will and is entirely your responsibility. *

I ACCEPT

Please check this box to agree that By completing this form, you understand you are RESPONSIBLE for your own process *

I AGREE

Street Address *

City

State

Country

Postal code

Phone Number *

Date of birth *

Marital Status *

Are you currently, or have you previously received any type of mental health services (psychotherapy, psychiatric services,etc.)? *

Are you currently taking any prescription medication for your mental health? *

Have you been diagnosed with any serious or chronic - mental, emotional, physical - disease, syndrome, or illness? *

Please state your diagnosis *

Are you currently participating in any other holistic or alternative therapies? *

If yes, please describe as this helps to understand what tools you currently have to work with. *

Please state the biggest challenges you are currently facing in your life - emotions, patterns, conditioning, relationships etc. *

Please state 3 things you'd absolutely love to create in your life. These can be anything from physical experiences to emotions *

Please set an intention for the inner work you are about to meet *

Please check this box to confirm you understand no refunds are given after the session, sessions or process has started *

I Understand

Please check this box to agree to respect the 24-hr cancelation and rescheduling policy. Failure to do so will result in the session being null and void. *

I Agree