Name*

First Last

Date of Birth

Phone / Mobile*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Relationship Status:

Current health concerns:

Current medications and/or treatments

Experience*

Which experience or retreat are you interested in or have you booked?

If interested in the Sedona Energy Alignment Weekend, which weekend do you prefer?

Under Which Name is the Experience Booked, if not yours?

Date Booked or Preferred

Fitness Level - Sedona is home to some of the most beautiful hikes and healing lands in the county. What is your hiking/walking ability so we can better determine which of the beautiful locations to visit?*

Beginner/Easy - Flat and even ground with maybe a gentle incline hike is good.
Moderate - Can do moderately uneven terrain with a 5-8% incline.
Advid Hiker - Love it all!
N/A - Indoor Session

Do you have a fear of heights?*

Yes! No climbing at all.
Moderate, mostly on skyscrapers.
I love all heights! No Fear!
N/A - Indoor Session

Have you ever had a energy healing session or any other type of energy therapy?

Yes
No

What is the name or the type of energy therapy?

If yes, when was your last session?

Number of previous sessions

How did you hear about me?

Melina Fuhrmann

Participant Form

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