Client Intake & Wellness Consent

To begin your healing experience, please complete this form first. Once submitted, you’ll be guided to schedule your session. I can't wait to meet you!

First Name *

Last Name *

Phone *

Email *

Which Session Are You Interested In? *

Complimentary Clarity Consultation

Hypnosis

Reiki

Sound Balancing with Tuning Forks

Biohacking with BrainTap

Bemer PEMF

NeuralChek Energy Scan (add on only)

What would you like help healing or working through at this time? *

Health Screening

Do you have any physical, medical, or psychological conditions? (Y/N) If yes – description.

Are you currently pregnant or trying to conceive?

Yes

N/A

Do you have any electrical medical devices such as a pacemaker or cochlear implant? *

Are you currently taking medications or supplements? *

Any areas of pain, sensitivity, or physical limitations? *

Hypnosis

Have you experienced hypnosis before? *

Yes

How long have you been experiencing the issue you’d like to work on? *

On a scale of 1–10, how motivated are you to resolve it? *

What specific outcome would you like to achieve through hypnosis? *

Sound Healing

Do you consent to light therapeutic touch and/or instrument placement during your session? *

Yes, I consent

No, I prefer no physical contact

Biohacking

Have you ever used a BrainTap headset or similar light/sound therapy device? *

Yes

Do you have any history of seizures, epilepsy, photosensitivity, blackouts, or migraines? *

Yes

If yes, please describe:

If yes, please describe: (copy)

Reiki

What are your goals for this Reiki session? (e.g., relaxation, stress relief, emotional balance, physical healing)

Are there any specific areas (physical, emotional, or spiritual) you’d like the session to focus on?

I understand that Radiance Wellness Co provides complementary wellness services and does not diagnose, treat, or replace medical or psychological care. I agree to communicate my comfort level during

I agree to receive email and text communications from Radiance Wellness Co regarding scheduling, and session reminders.

I understand that I can unsubscribe or reply STOP at any time to opt out of future messages. Standard messaging and data rates may apply.