Intake Form

First name

Last name

Age

Please use 3 words that describe how your life feels right now (and feel free to use more words to explain if you would like).

What is your primary reason for scheduling this session? What do you hope to achieve?

What should Ava know to best support you receiving your desired outcome?

Family of Origin Structure: Please describe your family set-up in childhood (i.e. I had a Mom at home, step-siblings around half the time, a big gap between me and other siblings, etc.), including what number you were in the line-up of children

Describe your feelings towards your Mother-figure while growing up (i.e. tense, good, loving but strained, non-emotional, etc.)

Describe your feelings towards your Father-figure while growing up (i.e. tense, good, loving but strained, non-emotional, etc.)

What are key events that have changed your life (positive or negative - including any trauma experiences):

What is your preferred reference to the connection between you and life - otherwise known as your big picture metaphysical perspective?

Source

God

Consciousness

Nature

Science

I haven't decided yet

Other

Please let me know if you have any of the following health needs that I should be aware of while using energy tools (like tuning forks):

Pregnancy

Pacemaker

Recent head injury (in last 6 months)

Terminal Illness

Other

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