SAMADHI HOLISTIC CENTER INC

Client Intake & Waiver Forms

FORM 1: Confidential Holistic Healing Client Intake Form

First Name

Last Name

Date Of Birth

Address

Street Address

City

State

Country

Postal Code

Gender

Phone *

Email *

Emergency Contact

Relationship

Emergency Contact Number

Current Health & Wellbeing

• Please describe any current physical concerns or diagnoses:

• Please describe any emotional/mental health challenges or concerns:

o If yes, please list provider type and nature of treatment:

• Are you currently receiving treatment from a medical or mental health provider?

Yes

No

Are you currently taking any medications, supplements, or herbs?

Yes

No

Please list:

Specific Needs or Intentions for Healing:

• What brings you to SAMADHI Holistic Center? What are your goals or intentions for healing?

Spiritual History (Optional):

Are there any spiritual practices or beliefs that are important in your life?

Yes

No

o If yes:

Contraindications Check:

Are you currently pregnant?

Yes

No

Unsure

Do you have epilepsy, heart conditions, or metal implants?

Yes

No

o If yes, please specify:

Are you in recovery from substance abuse or trauma?

Yes

No

Preferred Modalities

FORM 2: MEDIA RELEASE (Optional)

I By Selecting below grant permission to SAMADHI Holistic Center INC to use my photograph, video, or written testimonial for educational, promotional, or spiritual purposes, in alignment with its sacred mission. I understand my identity may be anonymized at my request.

Yes, I Give Permission

No, I Decline

FORM 4: CONFIDENTIALITY AGREEMENT

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

I grant permission to SAMADHI Holistic Center INC to use my photograph, video, or written testimonial for educational, promotional, or spiritual purposes, in alignment with its sacred mission. I understand my identity may be anonymized at my request.

Yes

No

"What is spoken in healing is sealed by Spirit. What is shared in trust shall not be broken." — Guardian of the Flame agree to maintain the confidentiality of any personal, spiritual, or emotional experiences shared by others during group or individual healing sessions at SAMADHI Holistic Center. This includes names, stories, or any identifying information. I will not record or distribute any part of the ceremony or session.

Clear

May this sacred covenant between healer and participant be held in honor by the divine and overseen by the light of truth.

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