New Client Questionnaire

First Name

Last Name

Phone

How High is your current stress level?

Not Stressful

Moderately Stressful

Very Stressful

Please describe any physical pain or discomfort you are experiencing and how long you have had these challenges:

Please describe any recent shifts in mood or emotional health:

What drew you to my services? What do you hope to gain from our session/sessions together?

Consent and Liability

Please confirm understanding by choosing the "AGREE" box below.

It is my choice to recieve this treatment. I realize the treatment is being given for the wellness of my mind, body and spirit. I understand that body/energy work are for the purposes of stress reduction, general relaxation and improvement of energy circulation, balance and flow. I understand this session can not take the place of any medical, psychological, financial or other professional service

AGREE

DISAGREE

AGREE

DISAGREE

I understand that all energy/body work offered at Sacred Element life or Zen Riot Studio is strictly non-sexual. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the session I scheduled.

AGREE

DISAGREE

After submitting this questionnaire Sacred Element Life will contact you to help assist setting up your appointment. After submitting once and receiving approval, you can book appointments as needed.

All sessions are held in confidentiality, and at no time will Jenn share your information without consent.

Full Payment is after the service is complete.