Thanks for trusting me to support you in your journey towards healing and empowerment. Please fill out the client intake form, the client consent and agreement form, and the self-assessment related to your session. These forms must be completed at least 48 hours before your session, one week before if your session is a Yoga Nidra.

The insight you provide into your overall state of being will be valuable for understanding any energy patterns and creating the focus of your session.

I respect your privacy and will use your information solely for our work together.

Client Consent & Agreement

Name

First Name

Last Name

Emergency Contact

Phone

Session Type

Date of Session

YYYY

Agreement & Consent: By typing my name below, I agree that I am voluntarily participating in Reiki /Yoga Nidra/Breathwork sessions offered by Ana Paliza-Brown at Mudita Massage. I understand that Reiki and Yoga Nidra are complementary therapies and are not a substitute for medical treatment. I agree to continue any medical treatment prescribed by my healthcare provider. I understand that the practitioner does not diagnose medical conditions, nor does he/she prescribe medications. I understand that the practitioner will explain the session process and techniques, and I have the right to ask questions and clarify any concerns I may have. I have been given the opportunity to ask questions, and my questions have been answered to my satisfaction. I certify that I have read, fully understand, and agree to the terms of this consent form. I understand that the practitioner will respect my privacy and confidentiality, except as required by law. I understand that the practitioner may need to touch me lightly during the session for Reiki and breathwork or to adjust my posture during Yoga Nidra. I give my consent for such physical contact. I understand that it is my responsibility to inform the practitioner of any medical conditions, injuries, or other concerns that may affect my ability to participate in the session. I understand that I am free to stop the session at any time if I feel uncomfortable or distressed and that I can ask the practitioner to modify the session as needed. I understand that payment is due at the time of the session unless prior arrangements have been made. I have read and understand the above agreement and consent to participate in Reiki/Breathwork, Spiritual Connection Journey and/or Yoga Nidra sessions.

Liability release: In consideration of receiving Reiki, Breathwork and Yoga Nidra services, I, my heirs, assigns, and legal representatives hereby release, waive, and discharge Ana Paliza-Brown, and her heirs from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in these services. By printing my name below I agree to this liability release.

Forms Form 3

Name

First Name

Last Name

Session Date

YYYY

Have you ever done breathwork with a practitioner? If yes, please share your experience. If you've already seen me for a breathwork session, you can skip this question.

Do you practice conscious breathing throughout the day?If yes, please describe.

Are you aware of any breathing patterns that you would like to change or work on? If yes, please elaborate.

Do you ever find yourself holding your breath? if so, when?

Are you able to fully inhale and fully exhale with the same ease?

Do you feel a connection between your pelvic floor and your breathing?

What three words would you use to describe your relationship with your breath?

What are you hoping to gain from this breathwork session?

Are you currently experiencing any physical ailments/symptoms that I should know about prior to our session?

Are you currently experiencing any mental, or emotional ailments that I should know about prior to our session?

Client Intake

Name

First Name

Last Name

Pronouns/Any other name you'd like me to call you by

Date of birth

YYYY

Are you currently experiencing any illness? Please explain?

Do you have any physical conditions or injuries that may affect your ability to receive Reiki, practice breathwork, or practice Yoga Nidra? Please describe.

Do you have any emotional or mental health concerns that you would like to share? Please describe.

Are you pregnant or trying to become pregnant?

Is there any other information you would like to share with me, and/or you believe is pertinent that I learn before our session?

Yoga Nidra Self-Assessment 2 3

Name

First Name

Last Name

Date of Session

YYYY

Have you practiced Yoga Nidra before? If so, please describe your experience. You can skip this questions if you've practiced Yoga Nidra with me in the past

Are there any specific areas of your life (physical, emotional, spiritual) that you would like to focus on during the session?

How would you describe your current relationship with your physical body?

If your body could speak, what would it say about its current state of being?

Are you experiencing any health challenges that currently restrict your daily life? Are you seeing a health practictioner for these challenges? If so, what type of practitioner?

Are you experiencing any pain in your physical body? Please explain

How would you you describe your relationship with your energy body?

Do you experience any difficulty breathing or notice any patterns of holding your breath? If so please explain

What is your overall energy level?

What are your sleep patterns like?

What is your current relationship with your emotional body?

What is your current stress level like?

Do you feel nurtured and supported by personal relationships?

Do you feel nurtured and supported in your career?

What is your current relationship with your mental body?

What is your current relationship to your spiritual body?

Do you feel a sense of connection to nature, others and source/god/spirit?

What do you see as ultimately most important in life?

Are there places in nature that feel particularly powerful to you?

What places in nature (or otherwise) feel particularly calming to you?

Is there any kind of music, place, color or symbol that you really, really dislike?

Are there any questions you have been hoping to find an answer to?

Is there a personal goal for inner transformation or healing (resolve) are you either working towards right now, or hoping to soon?

In a few words, how are you hoping to feel during and after your yoga nidra session?

Is there anything else you feel called to share before our session? And do you have any questions or concerns regarding our Yoga Nidra Session?

Are you currently experiencing any mental, or emotional symptoms that I should know about prior to our session?

Reiki Self-Assessment

Name

First Name

Last Name

What are you hoping to gain from this Reiki session?

Are there any specific areas of your life (physical, emotional, spiritual) that you would like to focus on during the session?

Is this your first time receiving Reiki? If not, is there anything you would like me to know regarding your previous experiences with Reiki? If you've already seen me for a Reiki session, you can skip this question.

How is your current relationship with your physical body?

How is your current relationship with your emotional body?

How is your current relationship with your mental body?

How is your current relationship with your spirit body?

Are you experiencing any pain at the moment? Physical or otherwise? If so, please describe.

Do you have any other questions or concerns regarding our Reiki session?

Spiritual Connection Self-Assessment 2

Name

First Name

Last Name

Date of Session

YYYY

Are there any specific areas of your life (physical, emotional, spiritual) that you would like to focus on during the session?

How would you describe your current relationship with your physical body?

If your body could speak, what would it say about its current state of being?

Are you experiencing any health challenges that currently restrict your daily life? Are you seeing a health practictioner for these challenges? If so, what type of practitioner?

Are you experiencing any pain in your physical body? Please explain

How would you you describe your relationship with your energy body?

Do you experience any difficulty breathing or notice any patterns of holding your breath? If so please explain

What is your overall energy level?

What are your sleep patterns like?

What is your current relationship with your emotional body?

What is your current stress level like?

Do you feel nurtured and supported by personal relationships?

Do you feel nurtured and supported in your career?

What is your current relationship with your mental body?

What is your current relationship to your spiritual body?

Do you feel a sense of connection to nature, others and source/god/spirit?

What do you see as ultimately most important in life?

Are there any questions you have been hoping to find an answer to?

Is there anything else you feel called to share before our session? And do you have any questions or concerns regarding the spiritual connection journey?