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Intake Form

Personal Information:

If this client is a Minor, please the following:

Medical History:

Concerns or Interests:

Life Events:

Agreement and Disclaimer:

I agree to participate in the healing process and I realize it is not psychotherapy or a replacement of psychotherapy. I take full responsibility for consulting with a medical doctor or therapist regarding any concerns about my participation. I agree to hold Mecca Wagner-Brown and Shana Boyer harmless for any complications resulting from this work.

Entering your name in the "Client Signature" box below will serve as your signature and you are acknowledging that you agree to participate in this process with full understanding and personal responsibility.

Disclaimer: Mecca Wagner-Brown dba Mindful InnerChange and Shana Boyer dba Energetic Awakening does not provide medical diagnosis, or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have.

By utilizing the services and information provided by Mecca Wagner-Brown and/or Shana Boyer, you acknowledge and agree to fully release, indemnify, and hold harmless, Mecca Wagner-Brown and Shana Boyer, and others associated with Mindful InnerChange and Energetic Awakening, from any claim or liability whatsoever, including without limitation, direct or indirect, special, incidental, compensatory, exemplary or consequential damages, losses or expenses.

Any information, stories, examples, or testimonials presented on the Mindful InnerChange website do not constitute a warranty, guarantee, or prediction regarding the outcome of a treatment with Mecca Wagner-Brown and Shana Boyer. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically permitted to do so by Mecca Wagner-Brown (dba Mindful InnerChange) and Shana Boyer (dba Energetic Awakening). By continuing to explore this website, or choosing to respond with and receive any services from Mindful InnerChange and/or Energetic Awakening, you agree to all of the above.