Please fill in this form and fax (303-652-3427) or email (starvibe@indra.com) to me.

CONSULTATION FORM
All information is private and will not be shared with any agency for any reason.<br>
Emails are not rented out to outside parties, ever.<br> 
If you need more room to write pertinent information, please do so.


Name(s) Please include billing name and or soul name and approximate age.



Email address and phone number that you wish me to call.



Experience with essences or energy medicine



What is your work situation, relationship to your job, or things that occupy your time?



Are you taking any medications at the present time? This includes pharmaceutical, homeopathic, herbal, or others.



Are there any additional therapies that you are involved with?



Do you have a regular spiritual practice or religious participation?



Please describe your living situation? Who do you live with? Where? 
Describe the geographic area and your favorite room? 



Please describe your diet briefly? Vegan, fast food, TAD (typical American diet), Instinctive, Kosher, Other?



What is your level of physical activity? Sports? Work?



Describe your most important relationships? Happy, Satisfied, Puzzled?



Please describe your physical health. Anything pressing? Anything recently observed? Anything chronic?



Where do you think you are emotionally? Joyful, Persevering, Hanging on, ready for change?



How would you describe your mental health?



Where do you see yourself in one year’s time, physically, emotionally, spiritually, or financially?



How about in five year’s time?



What is your favorite color?



What do you want from this work? 
Please prioritize this list starting with the things of maximum importance.