Complementary and Alternative Health Care Practitioner
CLIENT INTAKE FORM
Name Today’s Date
Address, city, state, zip code
Thank you for requesting spiritual healing. We will first discuss the issues for which you seek help. If you are asking for shamanic healing, I will consult my helping spirits for guidance and seek your permission to perform the services they recommend. If the spirits indicate no services are appropriate at this time, the session will be discontinued with no obligation.
Services: I provide shamanic healing including soul retrieval, extraction, power animal retrieval, and depossession; shamanic counseling; instruction in shamanism, and “The Journey” (spiritual work in which you face and deal with emotional, physical and spiritual issues), for which you will be in a lightly altered state of consciousness. All my work is performed with the guidance of compassionate helping spirits. You are free and able at any time to discontinue the work.
Professional Ethics: I will perform these services only with your advance permission and in accordance with ethical guidelines for shamanic and other healing work which include strict confidentiality and non-interference with others’ freedom of will. Some healing techniques are best performed while in physical contact with the client but` I will not touch you without your permission.
Fees: Most services are by donation in accordance with your means and the value you place on what you receive. A suggested donation for shamanic services is $75 to $150 per session (usually 1-1.5 hr.). For Shamanic Counseling and “The Journey” I charge $150/hour. However, you will not be charged more that $300 for any session.
My Qualifications: I am experienced in shamanic healing techniques such as extraction, soul retrieval, power animal retrieval, divination, depossession, and help in death and dying, and am a Certified Shamanic Counselor® (certified by The Foundation for Shamanic Studies (FSS) providing one-on-one training to help clients access their own spirit guidance. I am also an Accredited Journey Practitioner (TheJourney.com), practicing spiritual healing to help clients deal with longstanding emotional, physical and spiritual issues, and qualified as a 2nd Degree Reiki Practitioner. I have studied core shamanism extensively with FSS since 1984, trained with indigenous shamans in the US and Nepal, and undergone a rigorous training program for The Journey. Further information about my qualifications and publications can be found at www.worldshaman.org.
I am not licensed, certified or registered by the State of Colorado as a health care professional. You should discuss any of my recommendations about your health with a primary care board-certified physician. I do not carry liability insurance covering injuries caused by my acts or omissions. You agree not to hold me liable for any consequences of my services. I do not perform invasive medical procedures or medical services requiring a professional license, use X-ray or radiation devices, practice midwifery, massage or spinal manipulation, prescribe or administer prescription substances, offer medical protocols to pregnant women or cancer patients, perform, provide psychotherapy as defined in C.R.S. §12-43-201, or treat children under two. Children age 2-8 require parent permission for treatment and should be under the care of a licensed pediatric health care provider.
Read and Understood:/s/
Client Signature - type or sign your name
Ellen Winner, 1045 Toedtli Dr., Boulder, CO 80305, 720-635-7212
You may fill out the form here online, save it, and attach it to an email to firstname.lastname@example.org.
Do not try to “share” it as all the information you entered will be lost.
Copyright © 2004-2022, Ellen Winner, Healing in Consciousness
All Rights Reserved