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♥ Wild Heart Healing Arts♥ Wild Heart Healing Arts
  • Home
  • About
    • About Artemisia
    • Rescheduling Policy & General Considerations
    • Discounts & Scholarships
    • Land And Labor Acknowledgement
  • Contact
  • Work Together
  • Blog
  • Testimonials
  • Client Portal

Client Forms

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Client History Form

Client History Form

Please Note: All client information is held in the strictest confidence is never disclosed or shared without your explicit consent.
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Mailing Address

If I wanted to send you a gift, where would I send it? (I will not share your address or mail you advertisements.)

Emergency Contact

All questions are optional. They help me know you as you are today.

What is the most important thing that I should know about you right now?
Briefly outline your personal support system as it looks today (i.e., family, friends, health care providers, groups, etc.)
Any experience with meditation or mindfulness practices? How is this for you?
What kinds of personal work (if any) have you participated in or done?
Please describe any movement practice, exercise or physical activity that is present in your life right now. How is this currently working for you?
Are you taking any prescription/non-prescription medication or recreational drugs? If so, for what reason?

Medical Background & History

All questions answered below will help me work more effectively with you.
This is particularly helpful information for clients I work with in-person as I may engage your body in touch or movement.
Length of time in recovery & any additional details

Surgeries, Chronic Conditions & Injuries

Please list any history of surgeries, major illness, chronic conditions, accidents, injuries, or anything that might be relevant while working with you.Our work together may touch on all aspects of you as an emotional, psychological and physical being. Knowing what your body has being through can be quite helpful.
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Final thoughts:

Tell me more...

Please note:

artemisia shine is not a licensed physician/mental health clinician. The alternative healing services provided by artemisia shine are not licensed by the state of California nor are they a substitute for licensed medical care.

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Let's get in touch

Go ahead, send me an e-mail! I'm always happy to hear from you. I will do my best to respond within 72 hours.

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♥ About artemisia

artemisia shine helps people and communities get free. She is a somatic therapist and liberation warrior for other change-agents, healers, empaths, givers and highly sensitive people. She LOVES helping you listen to and honor the longing and intelligence of your heart as you connect with your innate body-wisdom and power. She thrives on being a warm hug and available hand in the scared, hurt places, a co-conspirator in the mischievousness, an ally for the oppressed parts and a raucous rabble-rouser that encourages you to play more wildly! Her greatest joy is to love you up as you embody your unique magic. She knows that together, we can all get more free.

♥ Find me here

  • artemisia shine
  • Wild Heart Healing Arts
  • PO Box 12026 San Luis Obispo CA 93406 United States
  • 707-234-5411
  • wildhearthealingarts.com

Land And Labor Acknowledgement
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©2011-2023 · artemisia shine: Wild Heart Healing Arts All rights reserved.
artemisia shine is not a licensed physician/mental health clinician.
The alternative healing services provided by artemisia shine are not licensed by the state of California nor are they a substitute for licensed medical care.

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