Spiritual coaching in a safe space
Please click the links below to download Intake Forms. Please read, fill out and/or sign the needed form and bring with you to our first meeting.
Please Note ; Hard copies are available.
All information is Strictly Confidential and will Not be shared with any one.
And please understand the more the information about you the Better, Please be Honest. I will then
Create a Protocol that Best fits you, your intentions. Thank you!
This is about You and your Divine Awareness, Divine Empowerment!
You are Not Broken and Don't Need to be fixed.
"Do you give permission for the Healing?"
Client name Last, first - middle. Date _________
Primary phone number Cell or Home. Work Phone. Email.
Marital status. Occupation. Birth date, time, location.
Please list any of the following conditions. All that apply.
Have you had a diagnosis ? Does it right feel to you? What are your symptoms?
What is your belief system? Do you feel comfortable with the word God?
Is God a loving God? Have you? seen a Chiropractor, Nephropathy? D.O.M. ?
Ayurvedic Practitioner? Homeopathic? ``Do you have an insurance plan?
Do you have a regular Doctor? What kind?
Do you remember a significant turning point in your life that may have
contributed to this condition?
How old were you? How many siblings?
Do you have Children?
Aids Allergies Anemia Arthritis Artificial joints Asthma Auto Accident
Back pain Broken Bones Cancer Diabetes Divorce Dizziness Epilepsy
Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease High Blood Pressure
Jaundice Kidney Disease Liver Disease Mental Disorder Nervous Disorder Physical Trauma Pregnant Now?
Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Thyroid Ulcers
Tuberculous Tumors Ulcers Venereal Disease Other Present Pains Anything else Not listed here?
Can you think of any Child hood Traumas? Any mid life Traumas or Crisis? Loss of Family or Friends? Pets?
Work place stress? Intimate Relationship stress or crisis, Breakups or Betrayal?
Homeless experiences? Heart Breaks? Healing Crisis? Financial Hardships or unexpected debts? Child Support?
Court Orders? Evictions? Loss of Pets? Loss of Possessions and or Property? Mental Break downs?
Emotional Break downs? See Continuation in 2019.
Safe Space Spiritual Coaching and or its affiliates or not responsible for any Medical Diagnosis or Medical Treatment please consult your Primary Doctor.