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Please use this Confidential form to briefly describe your reason for seeking Therapy services with Intentional Healing Space. Completing this form is not acceptance of care nor does it replace the enrollment process. We just would like to gather some information to make sure that we can best meet your needs. As always feel free to contact us by phone or email for additional questions or concerns. Yoga, Life Coaching,Workshops, Supervision, and Reiki can be booked directly by Calling the office. the information provided is received and reviewed exclusively by intentional healing space and
in accordance with privacy laws and best practice standards
and will never be re-disclosed or published in any form without proper consent.
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Reason for Referral
Please briefly describe the reason you are seeking services.