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About Cheryl Cheryl's Books Intuitive Sessions and Readings Lectures Reiki Workshops

Intuitive Energy Healing and Reiki Appointment Form

Please note that all written or sessional information will be confidentially maintained.
Date:
Name:
I am interested in an: Intuitive Energy Session
Reiki Session
Date of Birth:
Email:
Home Telephone:
Work Telephone:
Address:
City:
Province:
Postal Code:

Lanaguage/s: English
French
Other Languages

Emergency Contact Person
Name:
Phone:
City:

Medical Conditions:
Thyroid Disease
Hypoglycemia
Anemia
Allergies
Anxiety Disorders
Food Sensitivities
Mitral Valve
Prolapse Inner Ear Problem
Depression
Vitamin Deficiency  
Heart Disease
Cancer  
Other/s: (please list)

Purpose of session:
Do you have an established support system? Who?
Please share a future dream or goal that you have:

My favourite colour is:
I sometimes/ chronically have
pains/cramps/aches in the following places:
I feel the following emotions quite a lot or chronically:
I cannot feel the following emotions or body parts often/well:
My best time of the day is:
My worst time of the day is:

Please answer the following questions. Yes No
I have experienced a Reiki session before
I have had an energy balancing session before
I know about chakras
I have used holistic remedies for my growth and development
I have a spiritual path that I am consciously following
I have experienced trauma
I have difficulty adjusting to new situations and or people
I am generally uncomfortable with touch
I am generally uncomfortable expressing myself
I love myself
I accept myself
I am comfortable asserting myself
I feel like I belong
I feel connected to the world around me

Is there anything else you wish to share?


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Ottawa, Ontario. Canada