CLIENT INTAKE FORM This intake form will help you self-assess and focus your session, to maximize your healing. All information herein is completely confidential and used only for the purpose of facilitating your personalized healing. Please answer all questions that are relevant for you. Thank you! * Required Fields * Name: Birthdate: Spiritual Name or Nickname: * Phone: - * Email Address: * Sex: M F * Marital Status: Single Married Separated * In what areas of your life do you most want to create positive change? Please click on all that apply. finding my soulmate sacred partnership health right livelihood/wealth spiritual awakening enhancing creativity balance self-love and esteem letting go/healing grief weight and eating stress reduction conscious parenting increasing joy spiritual development/intuition other: * If you could set 3 goals for what you most want to accomplish with your session(s), what would they be? Consider all aspects of you life: physical, sexual/social, financial, emotional, creative, spiritual, environment/home. * In the average week, this is how many days I wake up happy or smiling: 0 1 2 3 4 5 6 7 * I am currently experiencing or being treated for: Alcoholism Drug Use Eating Disorder Diabetes Allergies Headache Epilepsy Heart Disorder Depression Cancer Immune Dysfunction Digestive Problems Other: My current religion or spiritual practice is: Agnostic/Believe in God in general sense Atheist/None Baptist Buddhist/Taoist Catholic Christian Episcopalian Evangelical Greek Orth. Hindu Islamic Interfaith Jewish Lutheran Metaphysical/New Age Methodist Mormon/LDS Pagan/Wiccan Presbyterian Protestant Russian Orth. Scientology Shamanic/Indigenous Spiritual but not religious Sufi Unitarian Universalist Unity/Religious Science/ New Thought Other: Please check any of the following healing methods you are interested in: couples counseling hypnotherapy shamanic healing individual counseling/coaching soul retrieval energy healing, chakras, Reiki angel/guide reconnection animal totems meditation & guided imagery affirmations that work! regression therapy (past-life and this life) chakra healing opening third eye & ear to awaken intuition releasing work/cutting cords spirit releasement, exorcism plant medicine grounding techniques dreamwork heart healings & meditations psychic/intuitive reading and channeling prayer letting inner child out (play, "sacred silliness") ritual Please complete the following if you are interested in relationship coaching/counseling: (If you are in a romantic relationship) Describe your current relationship. You may wish to address thing like: Do you feel she or he is a great match or are you uncertain? Describe your partner, degree of intimacy, length of relationship, commitment, any problems, and your satisfaction level. What techniques have you tried, individually and as a couple, to resolve issues (counseling, suggestions from self-help books, spiritual methods, etc.)? With what success? How can I support you both now? OR (If you are not in a romantic relationship presently) How do you feel about being "on your own"? Do you feel relieved, lonely, scared, angry, free, happy, sad, incomplete, complete? Do you feel like you have done enough letting go and healing? Are you clear about what you want in a relationship? Have you had unhealthy relationship patterns or poor choices of partners? Do you feel ready for love or do you feel you have some self-healing work to do, focusing on yourself for awhile? MAIN ISSUE: What issues or challenges are you facing right now? What have been long-term or lifelong challenge areas for you? What previous efforts have you made to solve these problems? What has worked, and what hasn't? What attracted you to working with me? Holistic approach to healing Interfaith/spiritual approach Law of Attraction taken deeper Specialization in self-love Specialization in conscious relationship I resonate with articles/info on website Just feels right/listening to intuition Referred by a friend Don't know Thank you. I look forward to working with you! - Rev. Taylor Kingsley, C.Ht. Phone Sessions Only: Click on your time zone: Eastern Central Mountain Pacific Hawaii Other Please list below up to 5 possible times in the next week, in order of your preference, when you would be available for your session: Initials: Please initial above that you have agreed to our terms. View terms

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