New Client Intake Form

Welcome to Spirit & Spark (Company)! You are required to fully complete this form before you can receive a service with us. By completing this form, you agree that your electronic signature and agreement to the statements are legally binding. Please ask us for assistance if you need help with this form. Spirit & Spark offers Psychic Arts and Wellness Services.

Today's Date *
Today's Date
Your Name *
Your Name
Would you like to receive special offers and promotions via email? *
We will never share or sell your information.
Your Phone Number *
Your Phone Number
Would you like to receive special offers and promotions sent to you via text message? *
Data rates may apply.
Your Mailing Address *
Your Mailing Address
Would you like to receive mail from us at this address? *
What is your birth month and day? *
What is your birth month and day?
You can put "99" in your birth year.
Yes, I understand that Practitioners at Spirit & Spark are not licensed, certified or registered as a provider of health care in this State. *
Yes, I understand that degrees, training, experience, credentials and other qualifications of the Practitioners at Spirit & Spark can be found at, or I may request them in writing at any time from *
It is recommended that before beginning any wellness plan, you notify your primary care physician or other licensed providers of health care of your intention to use wellness services, the nature of the wellness services to be provided and any wellness plan that may be utilized. It is also recommended that you ask your primary care physician or other licensed providers of health care about any potential drug interactions, side effects, risks or conflicts between any medications or treatments prescribed by your primary care physician or other licensed providers of health care and the wellness services you intend to receive. *
Yes, I acknowledge that I have been provided with a written copy of the statement outlined above, and I can request for it to be emailed to me, should I not be able to print it from this page. *
You can request a copy of the statement above by emailing
Yes, I understand that any of the services offered at Spirit & Spark are designed as a compliment to but not a replacement for appropriate medical care. I understand that nothing said, typed or produced by Spirit & Spark is intended or meant to diagnose, prescribe, treat a disease or take the place of a licensed physician, therapist nor will any practitioner prescribe medications or substances to me. *
Yes, I understand that all Psychic Arts, Wellness Services and holistic energy healing forms used at Spirit & Spark are used for stress reduction, relaxation and to help promote optimization of my spiritual state, and none of which is massage. I will remain fully clothed, other than removing my shoes. *
Yes, I understand that each form of energy work is different, and individual to me, and that my body may feel uncomfortable or unusual sensations such as tingling, minor heaviness, light pain or discomfort, heat, cold or other sensations. *
Yes, I understand that none of the services at Spirit & Spark are sexual in nature, and the practitioner will not touch me in any sort of sexual manner, nor will sexual advances by me be tolerated toward any practitioner at Spirit & Spark. *
Yes, I understand that only individuals that hold a Psychic Arts license are allowed to provide me with a psychic reading. *
Yes, I understand that services provided at Spirit & Spark have no guarantees, and by law are for entertainment purposes only. *
Yes, I have read and agree to the Privacy and Terms of Spirit & Spark, found at I also understand that I may request the Privacy & Terms statement to me in writing by requesting it at *
Your Electronic Signature *
Your Electronic Signature