solTERRA Wellness Center

INTAKE FORM

1017 Illinois Ave

Palm Harbor, Fl 34683

(727)452-7526 Fax (727)938-9439

Client Information

Name: ______

Date: ______

DOB: ______Time of birth: ______am or pm

Place of birth: ______

Address: ______

Phone: ______Email: ______Cell Phone:______Referred By: ______Occupation:______

Emergency Contact: ______Phone______

Do you have a script from your doctor for craniosacral therapy ______

Do you have a physical exercise program? Yes / No

How many times per week? ______

Please describe type of exercise? ______

What type of diet do you follow (ex: vegetarian, vegan or do you eat meat)? ______

Do you experience any physical pain? ______Where? ______

Please rate pain between 1 and 10 (1 being mild and 10 being severe) ______

Based on your intensions for this session, how do you feel emotionally in this moment? ______

______

Mentally, do you have constant thoughts, or uncontrollable, periodic neurosis? ______

Do you receive guidance and intuition through feeling, knowing, visions, hearing and/or other: ______?

Are you able to quiet your mind? ______Do you use any techniques (ex: deep breathing, meditation, or visualization)? ______

Do you experience any ascension type symptoms and how often: Dizziness___ Off Balance___ Not centered____Memory____ Headaches_____Ringing in the ears______Heaviness______Vision issues_____Voices______Other______

Are you diagnosed with any physical or mental condition: ______?

Are taking any essential oils, supplements, herbs or medications (list): ______

______

______

______

Do you cry? (circle one) None Sometimes Often Cannot Cry

Do you have an outlet for anger, frustration, or grief? ______Please explain______

______

What other therapies are you currently working with? ______

______

Are you open to natural solutions suggestions? ______

(30% discount off any Session for those who also get product suggestions-doTERRA Wholesale Account will be set up at session).

Circle any area that you know you need support and suggestions:

Digestion

Circulation/Heart Support

Central Nervous Support

Skin Health

Immune System Support

Hormonal Support

Gastro-Intestinal Support

Liver Support

Kidney Support

Respiratory Support

Nutritional Support

Why are you seeking Sessions with Elasa (1-5 Intentions)______

______

Session Types / 30min / 60min
Soul Sessions (1x)
Soul Session Members
CranioReiki
Aromatouch/
Essential Wellness Sessions
Child Wellness / $75
$60
$55
$60/adult
$20/child
**add on to a
session $20**
$60 / $150
$120
$80

Wellness Sessions with Elasa:

Sessions may include:

Soul Review, CranioReiki, SomatoEmotional Release, BioMat, doTERRA Essential Oils, Soul Certifications, Occupational Therapy, Yoga Therapy & Natural Solutions Opportunities.

CLIENT PLEASE FILL OUT BELOW

**Types of Sessions and Rates Requested from below:______

Goals established with Elasa:

1.

2.

3.

Plan of care: