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Axis Energy Healing

Client Intake Form

Energetic Family Healing

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This sacred healing works to clear non-beneficial energetic inheritances
through 7 generations of your family bloodlines.
Please complete this form with as much detail as feels comfortable.

Before you begin: In requesting this healing you are agreeing to step forward willingly to represent both sides of your family bloodlines. This is a powerful and sacred commitment. The information you share here helps focus the practitioner's attention and strengthens the intention held throughout the healing.

Your Details

First Name *

Please enter your first name

Last Name *

Please enter your last name

Email Address *

Please enter a valid email address

Phone / WhatsApp (optional)

Preferred Contact Method *

Phone Call

Please select a preferred contact method

Are you a new or returning client? *

New Client — €290

Returning Client — €240

Please select new or returning client

The Bloodlines

This information is essential for the healing work. Please include as much detail as you know. The land and roots of each parent hold particular significance.

☽ Mother's Bloodline

Mother's Full Name *

Please enter your mother's name

Maiden Name (if different)

Place of Birth (if known)

Disease / Health Patterns in the Mother's Line (optional)

Behavioural or Emotional Patterns (optional)

☉ Father's Bloodline

Father's Full Name *

Please enter your father's name

Place of Birth (if known)

Disease / Health Patterns in the Father's Line (optional)

Behavioural or Emotional Patterns (optional)

Your Intention

Main Reason for Requesting This Healing (optional)

Specific Intention or Focus (optional)

Your Support Kit

Every client must be in possession of either the emergency flower essence aura sprays or the emergency crystal set prior to the commencement of the healing. This is a non-negotiable part of the practitioner's duty of care.

Which support kit would you like? *

Emergency Flower Essence Aura Sprays

Emergency Crystal Set

Please select your support kit

Additional Support Kit (optional)

Add an additional emergency essences kit — €50 (RRP €90)

As a returning client you may already have your kit from a previous session. You are welcome to add an additional set at the special discounted price of €50 (retail value €90).

How would you like to receive your kit? *

Collect in person from the practitioner

Posted to me (postage cost extra)

Please select how you would like to receive your kit

Postal Address

Address Line 1 *

Please enter your address

Address Line 2 (optional)

Town / City *

Please enter your town or city

County / State (optional)

Eircode / Postcode (optional)

Country *

Please enter your country

Energetic Family Healing —

Additional support kit €50

Postage To be confirmed

Estimated total —

Consent & Declaration

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Thank you — your form has been received

Alice will be in touch with you shortly to arrange the timing of your healing.
Please take time to connect with your family bloodlines,
sit with your ancestry, and hold your intention with care.

axisenergyhealing.com

Practitioner Notes — Not visible to client

Session Notes

Kit Dispatched / Collected

Pending

Dispatched

Collected

Mother's Line — Date Completed

Father's Line — Date Completed