Remote & In-person 1:1 session Intake Form for adults and childrenPlease complete this form after you placed your order. Your Name * First Name Last Name Your Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * Country (###) ### #### Who is receiving this session? * If it is not you, please write the name of the recipient and relationship with you. Recipient's Date of Birth MM DD YYYY If date of birth is unknown, what's the current approximate age? List up to 3 goals or areas you would like to improve * Prioritize physical, emotional or mental aspects over other areas. Any medications or treatment you are currently on? On a scale of 1 to 5 (1 = mild, 5 = most severe/urgent), how would you rate the severity? * * 1 2 3 4 5 In-person or Remote? * In-person Remote Remote session options Offline Zoom Phone call Scheduling for remote session If you selected Zoom or phone call option, please list three times that work for you. Tomoko is available between 9am-6pm pacific time Monday through Saturday. Please complete the Disclaimer, Terms and Conditions Agreement linked in the next page after you click "SEND". * Yes, I understand. Dear first-clients, Please complete the Disclaimer, Terms and Conditions Agreement prior to your session. Disclaimer, Terms and Conditions Agreement Dear returning clients, please review and complete updated Terms and Conditions prior to your session by clicking the link below. Terms and Conditions Agreement onlyTomoko will be in contact with you shortly. If you don’t hear anything for more than 48 hours, please email info@flowinginlight.com.Thank you and see you soon!