Intake Form: One on One Kinesiology

One on One Kinesiology Appointment

Hello there, I’m looking forward to seeing you for an appointment! To help me get to know you better before our session, please fill out this intake form. It’s important for you to know: Rescheduling or cancellations require 48 hours notice to avoid fees. If you need to cancel or change your appointment within 24 hours, you’ll be responsible for paying the full consult cost. Cancellations or changes within the 48 hour period will incur half of your consultation fee. All my love to you!

Name*
Email*
Mobile No*
Skype*
Birthday*
Occupation*
Health History*
Have you experienced any major illnesses, conditions or injuries?*
Do you currently have aches or pains?*
Briefly describe your diet, including any issues, allergies or concerns:*
Where would you say your mind dwells?*
How would you describe your sleep?*
What do you feel is missing in your life?*
Current health/emotional concerns:*
What brings you to your session (reason)?*
Ideally, after the session, I would like to feel (3 words):*
Describe your current stress levels and rate your current stress 1 (nil) – 10 (extreme):*
Where in your body do you feel stress the most?*
Is there anything else you’d like me to know about you?*
I understand that Elena Pilch is a Kinesiologist and Intuitive Guide, not a medical doctor. It is understood and accepted that the treatment received by Elena Pilch is of a remedial therapeutic nature and not of a diagnostic/curative approach. I give permission for my health history to be kept on file for the purpose of Kinesiology sessions, all information within my file will be kept confidential at all times. Information is collected to assist me to better understand your needs so I can provide the best possible service for you. By sending this form back to Elena Pilch you are agreeing to these terms. PLEASE TYPE YOUR NAME TO AGREE - Thank you!*

Elena Pilch

Devotion

One on One Kinesiology Appointment

Elena Pilch is a Kinesiologist, Practical Intuitive Guide and Energy Healer.

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