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ABOUT
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INTAKE FORM
TESTIMONIALS
PURCHASE GIFT CARD
Schedule Now
INTAKE FORM
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First & Last Name
Email
Referred By:
What do you hope to get out of your session(s)?
What are your recurring thoughts, behaviors, or patterns you feel ready to work through??
What is the biggest challenge in your life right now?
How long has this been a challenge?
If healing allowed you to accomplish only one thing, what would you want that thing to be?
Please list any allergies:
Please list any metal in your body:
Are you pregnant?
Yes, I understand that doctor approval is required if I have heart arrythmia, a pacemaker, metal plates in body, implanted pumps & devices, epilepsy, are pregnant or have severe health issues.
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Informed Consent & Service Agreement, Policies, & Liability Waiver
I confirm that I have read, understood, and agree to the Client Consent, Policies, and Liability Waiver, and I voluntarily consent to participate in services provided by Elevate by Mia, LLC.
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