Crystal Healing Ritual - Intake Form

First name

Last name

Birthday

Month

Day

Year

Address

Email

Phone

Emergency Contact: Name/Phone Number

Do you have any physical restrictions or injury including ankle/knee/hip/neck/ shoulder injury or pain?

Do you have any health or wellness concerns?

Do you have any allergies/sensitivities to oils, incense, or fabrics?

Yes

No

If you answered Yes, please list your allergies/sensitivities:

Are you pregnant?

Yes

No

WHAT ARE YOU HOPING TO ACHIEVE FROM YOUR CRADLE BODY RITUAL SESSION? (physically, emotionally, spiritually or other) *

IS THERE SOMETHING YOU WOULD LIKE TO LET GO OF OR CALL IN ON AN EMOTIONAL OR SPIRITUAL LEVEL?*

YOUR INFRADIAN RHYTHM: a 28-31 day cycle that regulates the menstrual cycle. ARE YOU AWARE OF WHICH PART OF YOUR MOON CYCLE YOU ARE IN AT THE TIME OF YOUR SERVICE? (this will allow me to prepare your herbal blends to support what your body is needing)*

MENSTRUATION ( the 1 - 7 days of your period)

FOLLICULAR (the 7 to 10 days after your period)

OVULATORY (the to 4 days in the middle of your cycle)

LUTEAL (the 10 to 14 days between ovulation and your period)

NO LONGER (historectomy / menopause / pregnant/ other)

HOW DID YOU HEAR ABOUT NORTHERN ALKEMI BEAUTY?

DO YOU GIVE PERMISSION FOR PICTURES & VIDEOS FOR THE PURPOSE OF DOCUMENTATION, POTENTIAL ADVERTISING AND PROMOTIONAL PURPOSES?*

Yes

No

YOUR SATISFACTION AND SAFETY IS MY NUMBER ONE PRIORITY TO ENSURE YOUR WELLBEING BEFORE, DURING AND AFTER YOUR TREATMENT. PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND CHECK MARK BELOW:

I’ve shared all relevant details about my health history, including any medications I’m currently taking and any past reactions to products or medications that might affect or interfere with this treatment.

I understand that there may be other factors that could affect how well I tolerate the treatment. I’m also aware that there are some risks involved, and in very rare cases, I might experience skin irritation or discomfort.

By proceeding, you confirm that you fully understand the service you’ve requested and the associated risks. You’ve shared any relevant pre-existing conditions, allergies, or sensitivities with your service provider. Northern Alkemi Beauty and the service provider are not responsible for any dissatisfaction, discomfort, injury, or damage that may occur as a result of the service.

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