Healing with Holly Conetta Intake Form

New Client Intake Form

Healing with Holly Conetta, LLC

This form helps me understand you as a whole person so I can best support your healing session. Please share only what feels comfortable. All information is confidential

First name

Last name

Birthday

Month

Day

Year

Email

Phone

Address

How did you hear about me?

Reason for Coming → Primary reason for seeking a energy healing session

Living conditions -→ Do you live alone, have a partner, children, or pets?

If you have children, please list their ages.

Daily Activities → Daily routines, occupation, or energy demands

Holistic Healing Practicies → List other holistic healing modalities you have experienced

Health/Medical/Surgical History

Please include illnesses, diagnoses, or surgeries and approximate dates.

Accidents/Broken Bones

Please include approximate age or year of accident/broken bone

List medications, supplements, herbs, or homeopathics.

List allergies or sensitivities

Physical care practices

Diet & nutrition, sleep (hours per night / challenges), exercise (type & frequency)

Lifestyle factors that may influence well-being

Are there any lifestyle habits that you feel may impact your energy, stress levels, or sleep? (Optional – share only what feels comfortable)

Are there any addictive substances or habits you feel impact your well-being (past or present)

Pain Awareness → Do you experience pain in your body? Pain levels: where is the pain experienced and how severe is the pain (1=minimal, 10=extreme pain)

Stress→ Stress levels as it relates to your personal life, work, or other. Please rate 0=none, 10=extreme stress for each category and explain what the stress is related to.

Personal stress (0 = none, 10 = extreme)

Work life stress (0–10): ___

Other stress (0–10): ___

Anxiety→ Axiety levels as it relates to your personal life, work, or other. Please rate 0=none, 10=extreme anxiety for each category and explain what the anxiety is related to.

Personal anxiety (0 = none, 10 = extreme)

Work life anxiety (0–10): ___

Other anxiety (0–10): ___

Emotional and Spiritual Support → What tools or practices do you use to relax or reduce stress? Do you feel emotionally or spiritually supported in your life right now? What or who provides that support?

Prompt: meditation, prayer, breathwork, yoga, time in nature, etc.

PEMS Wellness Assessment - The PEMS model, which stands for Physical, Emotional, Mental, and Spiritual, serves as a comprehensive framework for understanding holistic health and well-being.

How would you rate your level of wellness in these areas, where 1=low level, 5=high level.

What would you like to experience, feel, or shift as a result of this session?

Are you currently working with any healthcare providers for physical or emotional concerns?

Trauma Awareness

Consent & Understanding (Checkboxes – required)

I understand that both Healing Touch and sound healing are biofield therapies and are complementary, energy-based modalities that do not replace medical or mental health care.

I understand I may pause or stop the session at any time.

I consent to receiving Healing Touch services.

I consent to receiving Sound Healing services.

You will be fully clothed and laying down on a massage table with a blanket. Your comfort level with light, non-invasive touch (over clothing):

Comfortable

Prefer limited touch

Prefer no physical touch

Special Considerations/ Medical Awarness: Are any of the following currently relevant to your health care?

If you selected “History of seizures,” please share anything you feel is important for me to know, frequency, triggers, last occurrence, or any current medical guidance.

Is there anything else you would like me to know about you before your session?

Emergency Contact

Thank you for completing this intake form. What you’ve shared allows me to offer informed, intentional care, supporting a calm, restorative session that honors your healing journey, comfort, and well-being.

New Client Intake Form

New Client Intake Form

Contact Holly