Flourish by Design Intake Form Spam protection, skip this field Hello! I'm so excited for our work together. I look forward to aligning with you to clear out the old gunk that holds you back, and guiding you into a new life that is aligned with your desires, values, and intentions. I just need a little bit of information from you before we dive in. Today's Date Month January February March April May June July August September October November December Nothing found Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Nothing found Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 Nothing found Your Name Your Birthday Month January February March April May June July August September October November December Nothing found Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Nothing found Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 Nothing found Street Address City / State / Zip / Country Email Emergency Contact Do Any Of The Following Apply? (optional) I Have A Pacemaker I Have Other Implanted Medical Devices I Am Pregnant Are you being treated for any medical conditions, including allergies? What are your desired goals and intentions for our work together? Energy healing is not a replacement for medical care, nor is it a substitute for professional psycho-therapeutic or counseling sessions in the treatment of any mental health issues or disorders. I understand that if any facilitator makes any suggestions regarding supplementation of any kind, such as vitamins, minerals, herbal preparations, or any compounds or any external remedies of any kind, that I use or ingest such at my own risk, with the recommendation that I seek the advice of a physician or my health care provider before using any such remedy. I understand that in a minority of Emotion Code sessions, the release of trapped emotions or other energies may result in “processing” where echoes of the emotions released may manifest in temporary physical or emotional discomfort, and that this “processing” appears to be a normal part of regaining energetic balance. I understand that Reiki/Emotion Code/PSYCH-K® and any other forms of energetic healing and/or energy transmission are stress reduction and relaxation techniques. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Anné M. Klint and Flourish by Design from any and all claims or liability of any kind or nature arising out of or in connection with my session(s). No representation is made or intended as medical advice and should not be used for diagnosis or medical treatment. If you have questions or concerns about your health, contact your healthcare provider. No claims are made regarding healing or recovery from any illness. All sessions are confidential, and your personal information will not be shared without your express, written consent. I understand that by signing this form by typing my name into the box below that I fully consent to participating in Reiki/Emotion Code/PSYCH-K® and any other energetic healing sessions with Anné M. Klint. Legal I've read and I accept the terms and conditions of service. Signature