Question 1 of 14

Please share these details

• Full Name

• Email Address

• Phone Number

• Country of Residence

• Date of Birth

• Emergency Contact Name & Phone

• Relationship to Emergency Contact

Question 2 of 14

How would you describe your current emotional and mental wellbeing?

Question 3 of 14

Do you currently have any medical conditions or health concerns that may affect participation?
Yes / No
If yes, please describe:

Question 4 of 14

Are you currently under the care of a healthcare professional (doctor, therapist, psychologist, psychiatrist)?
Yes / No
If yes, please describe:

Question 5 of 14

Have you ever been diagnosed with a psychological or psychiatric condition?
Yes / No
If yes, please list diagnosis, dates, and current status:

Question 6 of 14

Have you ever been diagnosed with, or experienced symptoms associated with:

• Schizophrenia

• Schizoaffective disorder

• Psychosis

• Delusional disorder

• Bipolar disorder involving manic or psychotic episodes

Yes / No / Unsure

If yes or unsure, please provide details and indicate if you are currently receiving professional support:

Question 7 of 14

Are you currently taking psychiatric or psychological medication?
Yes / No
If yes, list medication, dosage, frequency, duration, and prescribing doctor.

Question 8 of 14

Why are you drawn to this healing journey at this time? And, what would you most like to release, shift, or transform?

Question 9 of 14

What forms of inner work or personal development have you explored? Please elaborate on any of the below:

• Therapy

• Meditation

• Energy healing

• Breathwork

• Somatic work

• Spiritual practice

• Plant medicine

• Coaching

• Personal development programs

• Other

 

Please share relevant experiences:

Question 10 of 14

Is there anything else Rhiannon should know before beginning this work?

Question 11 of 14

Participation Agreement & Liability Waiver

Nature of the Work

• This work involves somatic energy healing, intuitive channeling, shamanic energetic practices, and spiritual guidance.

• It is not psychotherapy, psychology, psychiatry, or medical treatment.

Practitioner Status

• Rhiannon Heins is not a licensed psychologist, psychiatrist, therapist, or medical practitioner.

• She does not diagnose, treat, cure, or prevent medical or psychological conditions.

No Guarantees

• Healing is highly individual; no specific results are promised or guaranteed.

Personal Responsibility

• I accept full responsibility for my physical, emotional, psychological, and spiritual wellbeing.

• I will seek professional support if needed.

Energetic Boundaries

• Sessions and energy work occur only during scheduled sessions or explicitly agreed activities.

• I understand that energetic support does not continue outside scheduled sessions unless agreed.

Integration Responsibility

• I understand that experiences may continue integrating between sessions and after the program.

• I accept responsibility for my integration process.

Client Conduct & Container Integrity

• I agree to honor respectful communication, personal responsibility, and container boundaries.

• Rhiannon reserves the right to pause or terminate participation if safety or integrity is compromised.

Screening & Eligibility

• Participation is subject to review of this intake form, even if payment has been made.

• If this work is not deemed suitable prior to the first session, a full refund will be issued (excluding payment processing fees).

Release of Liability

• I release Rhiannon Heins, Intuitive Rebirth™, and all representatives from any claims, damages, or liabilities arising from participation.

Confidentiality

• All information shared is treated confidentially, except as required by law.

Question 12 of 14

I confirm that all information provided is truthful and complete.

Question 13 of 14

I understand the nature of this work and consent to participate voluntarily.

Question 14 of 14

I accept the Participation Agreement, Liability Waiver, and additional clauses regarding energetic boundaries, integration, and conduct.