Intake & Intention Form

Date when you fill in the form

Day

Month

Year

First name

Last name

Email

Phone

Emergency Contact: Name + phone

How did you know about riverleaf?

Which sessions would you like to book?

Why are you coming for this session? What would you like to work on?

Are you less than 3 months pregnant?

Y

N

N/A

Do you have any metal implants, plates or other metallic items (other than tooth fillings) in your body? [this question is applied to if your session includes sound therapy]

Y

N

N/A

If so, where? any complications/pain

Do you have seizures of any kind? [this question is applied to if your session includes sound therapy]

Y

N

N/A

Are they Grand Mal (now known as ‘Tonic-clonic’)

Y

N

To your knowledge, have your seizures ever been triggered by sound?

Y

N

If so, please give details

Do you knowingly have any other condition that is triggered by sound – please give details [this question is applied to if your session includes sound therapy]

Do you have a severe physical or mental health condition?

Y

N

Do you have mild to moderate mental or physical health condition?

Y

N

How do you manage your symptoms?

How frequently do you experience them?

How severely do you experience it on a scale of 1 being hardly detectable to 6 – severely debilitating?

Are there any known triggers?

Which months would you like to receive your session?

Which time slot are you likely available?

Wednesday afternoon

Wednesday evening

Thursday afternoon

Thursday evening

if you haven't worked with me before, an intake video call is required. Can you give 3 dates & moments in the coming week for an intake call? Once you receive the email with intake call, please also confirm it.

Would you like to join my monthly riverleaf newsletter?

Yes, please

No, thank you

I am already in

Do you have any question?

1:2:1 sessions

To better understand your needs and provide a tailored session experience,

please complete this form after booking your session.

If you haven’t worked with me before, I’ll be in touch soon to schedule an intake Zoom call."

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1:2:1 sessions

​

To better understand your needs and provide a tailored session experience,

please complete this form after booking your session.

If you haven’t worked with me before, I’ll be in touch soon to schedule an intake Zoom call."