Intake form

Name *

Email address *

What type of healing session are you interested in?

Have you previously received auric magnetic healing?

What are your primary reasons for seeking healing?

Please select at least one option.

Stress relief

Emotional healing

Physical pain management

Spiritual growth

Energy balancing

Please describe any specific issues or concerns you would like to address during the session.

How did you hear about pure energy wellness?

Please select at least one option.

Social media

Word of mouth

Online search

Event or workshop

What is your preferred method of contact?

Do you have any medical conditions or allergies that we should be aware of?

Which service or services are you interested in?

Please select at least one option.

Auric magnetic healing

Remote healing sessions

Reiki sessions

Additional questions or comments

Pure Energy Wellness