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Spiritual coaching in a safe space

Intake Forms

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.  

            Health information. 

            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.      


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