New Client Questionnaire - Amâeil (Melinda Urban): Intuitive Counseling & Krystal Lightbody Healing

New Client Questionnaire

Please take the time to read this note AND the Terms and Conditions prior to submitting this form below, and note that advance payment is required to book an appointment once I respond to you.

If you’re seeking an appointment with me for the first time, please complete the following form to the best of your ability. This makes it easier to connect, determine whether I’m an appropriate support for you, and arrange appointment logistics. Your information is kept confidential for my records only, and is sent directly to my e-mail once submitted. Sincere requests only please. Once you complete the form, click on "submit" and you will see a message that it's submitted properly. Please be sure to fill in all the *required fields or it will not submit. The form is working. If you're still having difficulties, it could be due to negative interference in your field or the device you're using. Please contact me by e-mail with the same information as on the form to expedite your session request. Thank you.

Today's Date *

Example format: Mar 14, 2021

How did you find out about my services? *

If you were referred please let me know who referred you so I can thank them. Or indicate n/a.

Full Name: *

First & Last Name

Phone: *

This is a text field to allow all phone number formats. Please include your area code and full phone number. Examples: (999) 999-9999 OR 999 9999 99999

E-mail address: *

Moving forward in our communications, please check your junk mail/spam for e-mails from me. Gmail often puts e-mails into junk mail. Hotmail and Yahoo addresses frequently bounce back. If at all possible, please use an alternative, and add my e-mail address to your contacts or whitelist my address to help ensure that you receive correspondence from me once you submit this form. Thank you.

Sessions may be conducted by skype (voice only) if you wish. If so, please provide your skype address or indicate n/a. This will then be the format for all your sessions.

State/Province: *

Country *

Your Time Zone: *

Please indicate who this healing is for: *

myself

my child

my animal companion

couples counselling

Please note: 17 years of age and younger is a considered a child. If you are contacting me on behalf of another adult, such as a family member or friend, that individual will have to contact me directly.

If this session is for you please indicate your age, or indicate n/a: *

If this session is for your child please indicate his/her age, or indicate n/a: *

In 4-5 sentences, please describe the SPECIFIC primary concern for which you would like support now. Further details of your concern and any helpful history will be obtained in the healing session itself as there’s value in doing that together. I do not accept advance e-mails of your history or concern. *

How long has it been this way? *

Please list what have you already undertaken to address this issue? Examples: naturopathy, counselling, hands-on healing, cranial-sacral therapy, multi-dimensional healing, etc. *

So that I may understand your experience with healing, please list the types of healing you have undertaken during your healing journey. Examples: yoga, meditation, acupuncture/TCM, reiki/passive energy healing, naturopathy, chiropractic, energetic matrix, chakra balancing, hypnosis, life coaching, etc. *

If this session is for you, have you previously participated in any COUNSELING sessions that addressed your emotions, inner child or family of origin? *

yes

n/a this session is not for me

If this session is for you, please give me a sense of the reason, how long ago, and for how long you participated in that COUNSELING. If this session is not for you, indicate n/a. *

Is there any further information that you feel is vital for me to know in this first step?

Are you ready to move forward with healing this issue in your life? Please indicate: *

We will arrange a specific appointment by e-mail. For now, please indicate the different periods when you're generally available for a healing session. *

Appointments are available Monday to Thursday 10 a.m. to 6 p.m., and Friday 10 a.m. to 3 p.m. EST.

If your availability is very limited then please list three specific dates and times you already have in mind (in your time zone). I will do my best to accommodate you within my office hours, and we'll confirm this by e-mail.

NOTE: Appointments are only available Monday to Thursday 10 a.m. to 6 p.m., and Friday 10 a.m. to 3 p.m. EST.

I have read and agree to all the Terms and Conditions, including my responsibilities, all payment terms and cancellation policies, as outlined here: https://melindaurban.com/book-a-healing-session/what-to-expect-fees-agreements-responsibilities/. I understand that I am fully responsible for my choices and decisions to undertake healing for myself or on behalf of my child/children, and any animal companions, and any conditions that may or may not occur in conjunction with the healing. Please type your full name in the field.

Please enter your full name.

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