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Blissed Life Coaching

New Client Application

Thank you for choosing me as your coach. I am so excited to work with you and witness your growth. This is amazing stuff. But, before we begin, I just need you to answer some quick questions. Please answer the ones that apply to you. This is only for my personal record and will not be shared.

Please copy this questionnaire and medical disclaimer into a “Word” document and email your complete and initialed version to

I offer Reiki, Intuitive Healing, Body Ecology, Raw Foods, Intuitive Eating, and  Life Coaching and Autism Healing Consultation. Your session is designed especially for you depending on what you need and desire.

  1. Full Name:
  2. Are you joining for your child? If so, what is her/his name/age
  3. Contact Info: (how do you wish to be contacted? Phone, email, Skype name)
  4. What services are you interested in? (List all)
  5. Have you ever had energy healing or Life coaching previously?
  6. What would you like to work on?
  7. Do you have any serious health concerns that you need to share?
  8. If applying to a healing program or class, please share a few sentences about why you believe this program and you are meant for each other.
  9. For the Heal Artfully program please attach your daily diet, favorite foods, and known allergies or food sensitivities

Medical Disclaimer:

Gina LaVerde is a Certified Reiki Practitioner and Reiki Master Teacher, Body Ecology Coach, Raw Foods Coach, Life Coach, Intuitive Healer and professional writer and business owner.

Gina LaVerde is not a licensed physician, and does not share medical advice. Her services and the information provided on this website are intended as educational material, and have not been approved by the FDA.

Before choosing to work with Gina LaVerde as your health coach, life coach or energy healer, you must agree to these terms.

Reiki is an ancient healing art that is non-invasive, all natural and safe. Reiki cannot cause harm and can be done with or without touch.  A Reiki practitioner taps into “source” energy and allows it to flow through the client, using specific hand positioning on or above the 7 chakras and other places on the body. The intention is to bring relaxation, clarity and assistance in healing your life on emotional, physical and mental levels. It can also be done from a distance. Reiki is now used in many hospitals and western –based healing facilities as a complimentary practice.

Gina’s intuitive healing services are an extension of her Reiki practice, and are safe, non-invasive, natural and can be done with or without touch and from a distance.

This treatment is alternative or complementary to healing arts services licensed by the state of California. These services are not licensed by the state of California.

We strive to provide you with the most well researched and up-to-date information, but suggest that you continue your own research. Only you have the power to know what’s best for your health.

Gina LaVerde has studied Autism, Digestive Recovery and Body Ecology Diet coaching with Donna Gates; Shamanic Healing with Joan Forest Mage; Movement, Sound and Sensory Healing with Joan Forest Mage; Chinese Herbalism and Qi Gong at Emperor’s College of Traditional Oriental Medicine;  and Reiki 1, 2  and master levels with Andrea Friedman and Laura Bruno.

She continues expand her education and is currently taking classes in Chinese Herbalism, acupressure, intuitive healing, Bhakti yoga, and nutrition.

Gina received her BA in creative writing from Columbia College in Chicago, and has written and researched professionally for 10 years in the field of health.

Please check with your preferred medical professional for any medical questions, and before you decide to make dietary or life changes.

Gina LaVerde is not responsible for any misunderstanding or problems that occur as the result of use of her coaching services or website.

Note: any payment for services represents your agreement to our terms of service and medical disclaimer.

We make no guarantees, but we always strive to provide you the best services. No refunds will be rewarded once services have been rendered. However, if you are unsatisfied with your results, you may re-take any class or program that we offer, or trade for another service.

** If you agree with the medical disclaimer above and wish to retain Gina LaVerde’s services please initial here: _____________________________________________


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