Intake Form

First and foremost I want you to take some time and sit with yourself to acknowledge in yourself, how good it feels to choose you. Even though it is scary or uncomfortable, you took the first step in showing up for yourself in your journey inward. That takes a huge amount of courage, trust and strength…put your hands over your heart space send yourself thanks and love.

Second I would like to thank you for trusting me to guide you and share my tools with you. I do not take the sacredness of this space lightly. I uphold the upmost integrity, confidentiality, authenticity, trust and compassion in this space. Endless Love.

Surrender. Trust. Forgive. Let Go. Be Present. Be Love

I am grateful to hold space and support you as you heal yourself and align with the True You.

Endless Love,

Jill

Which Receive offerings would you like to book with Jill?

What about this type of experience attracted you?

What is your intential in working with Jill, or what do you hope to gain from this experience?

Have you done anything similar before?

In your own words, where would you like more clarity in your life?

Please describe any current practice or belief that is related to your personal growth.

Please list any training or healing modalities that you have participated in that have guided you.

Please tell Jill about your physical health (list any major illnesses, surgeries, any pervious injurious or physical conditions that may impact your well-being)

List any allergies or medications.

Current psychotherapy, counseling or psychiatric treatment? Please describe:

Your Name

Phone Number

Emergency Contact Name

emergency Contact Email

Emergency Contact Phone Number

Your Occupation

Your Employer

Please Choose Your Family Situation

Single Married / In Relationship

Do you have any children?

Yes No

Please list any hobbies or particular interests.

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