Intake Form — Echo & Era | Past Life Regression | Kansas City or Virtual

Intake Form

All clients are required to complete this questionnaire prior to the start of our session. Please do not fill out this form without booking a session on Calendly, first.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Have you meditated before?

Yes

No

If yes, what was your experience?

Have you done Past Life Regression before?

Yes

No

If yes, what was your experience?

Do you have a religious affiliation?

Do you have any medical conditions I should know about?

Do you have any specific goals or intentions for this experience?

Please provide an emergency contact person

First Name

Last Name

Phone

(###)

###

####