Return to Self

Return to Self - Client Intake Form

Thank you for your interest in Return to Self. This information helps create a safe and supportive experience.

Personal Information

Full NameDate of BirthEmailPhoneEmergency Contact (Name & Phone)

Your Intention

What brings you to Return to Self?

Stress reliefRelaxationEmotional healingPersonal growthCuriositySpiritual explorationOther

What would you like to receive from this experience?

Health Information

Are you currently pregnant?

YesNo

Have you ever been diagnosed with any of the following?

Heart conditionEpilepsy or seizuresHigh blood pressureNeurological conditionBipolar disorderSchizophrenia or psychosisPTSDSevere anxiety or panic disorderOther

Are you currently receiving treatment from a physician, therapist, or mental health professional?

YesNo

If yes, please explain briefly:

Are you taking any medications that may affect your physical or emotional state?

YesNo

If yes:

Previous Experience

Have you experienced any of the following?

MeditationBreathworkKundalini ActivationEnergy healingYogaNone

Agreement

I confirm that the information provided is accurate to the best of my knowledge.

SignatureDate

Return to Self

Instagram @returntoselfwithsamina
Email info@myreturntoself.com
Winter Garden, FL

Disclaimer

Return to Self sessions are intended for personal growth, relaxation, self-awareness, and well-being. They are not medical treatment, psychotherapy, counseling, or a substitute for professional healthcare.