This document is a comprehensive client intake form template designed for gathering detailed personal, health, and service preference information from clients in holistic or complementary health practices.
- Client personal details: It collects full legal name, preferred name and pronouns, date of birth, phone, email, preferred contact method, and emergency contact information. 12
- Presenting concerns: Clients describe their current issues, duration, intensity, symptom timing, affected body areas with sensations, and associated emotional or energetic patterns. 34
- Health, lifestyle, and energetic history: Includes medical history, medications, allergies, prior spiritual or energetic work, self-care routines, substance use, major stressors and supports, and ancestral or family patterns for healing. 56
- Boundaries and safety: Captures physical contact preferences, comfort with smudging and topical herbal applications, scent or herb restrictions, trauma or seizure history, current mental health or medical providers, and accessibility needs. 78
- Intentions and service preferences: Clients state desired outcomes, select preferred approaches such as herbal tinctures or ritual design, specify involvement level, and note spiritual names or traditions to honor or exclude. 910
- Service selection and initials: Clients check services they are interested in, including herbal tinctures, sea moss blends, rootwork, hex removal, space cleansings, aura rebalancing, ritual design, and aftercare, providing initials for consent. 1112
- Practical details: Preferences for session type, best appointment times, financial or scheduling constraints, and referral source are recorded. 1314
- Acknowledgement and consent: Clients acknowledge the complementary nature of services, provide signature and date, consent to contact providers if necessary, and permit appointment reminders. Optional notes for the practitioner are also included. 1516
