Name at birth*
Name most commonly used (if different from above):
What are the challenges you are having currently / What would you like to heal?
How long have you been dealing with these issues?
What was happening in your life around the time these issues surfaced?
When you think about these issues, where does your body react?
Where do you feel the physical manifestations of the issues?
What methods have you used to heal these issues and what has worked and not worked?
In as much detail as possible, please share your childhood experiences with me especially
your relationship with your caregivers (parents, grandparents) and siblings and any other
family member that was a significant part of your upbringing.
How do you self-soothe, self-medicate?
What is your blood type?
What do you eat mostly?
How do you exercise:
How do you express / release your emotions?
What are your spiritual beliefs if any?
* denotes required fields
“If you’re looking to go deep on many levels, this colonic spot incorporates energy work, essential oils, crystals and aromatherapy.”