Name

First Name

Last Name

Phone

Address

Birthday

Where did you hear about me?

Would you like to be added to my newsletter list?

Yes

No thank you

Relationship Status?

Where do you currently live?

Do you have children ? and/ or pets? Names and how many.

Occupation?

Tell me why you want to work with me and what you hope to get out of our time together?

What symptoms are you currently experiencing? Please include physical, emotional, mental, and spiritual symptoms.

Have you seen a medical professional for these symptoms? Explain results.

On a scale of 1-10 how happy are you in your life in general? ( 1 is very unhappy and 10 being super happy)

On a scale from 1 - 10, how severe is this issue in your life?

When did this problem start? what was happening in your life at the time?

Disclaimer: Leah Wentworth should never be used to solely diagnose, treat, cure, or prevent disease or psychological disorder and is not a substitute for licensed medical or psychological treatment. Leah is not a doctor or therapist. Leah is a certified Transformational Life Coach, a Reiki Master, and EFT practitioner. She strives to support you to create balance in your energy system and connect with your inner wisdom to restore your body’s natural healing intelligence. It is likely that in your session(s), the things that are blocking your natural healing and wellbeing will rise to the surface and together you can address them and release them. This is a team effort and YOU are a key player!

I agree

Financial Policy: Your appointment time is reserved for you! If you should need to change it for any reason please Kindly give 24 hours notice. 1st missed or cancelled less then 24 hours appointment is forgiven, 2nd one I will ask you to pay 1/2 rate, and 3rd you will be expected to pay full fee for that missed appointment. Any bank fees associated with returned checks will be your responsibility.

I agree

Your Privacy: Leah will hold all your information in complete confidentiality. Leah will not disclose any of your personal information without your written consent, unless required by law. - Leah Wentworth

I acknowledge

The Yurt: You will meet with Leah in her Yurt home office. This yurt was built set in nature as a sacred space for healing. The yurt is a 3-5 minute walk from the parking area so please come early enough to find your way there by your scheduled appointment time. Take this walking time to enjoy being in nature, let go of your day, and set your intentions for your session with Leah. Please watch your step and pass at your own risk. You will receive further instructions before your 1st appointment

I agree to pass at my own risk

If client is a minor, a parent must sign here (by typing name in box below) to give permission for me to see the client