Client Information Form

I understand that holistic healing treats the whole person: mind, body and spirit, as every issue has an emotional, mental, physical and spiritual component. I also understand that the mind / body has the ability to heal itself, and that long-term imbalances sometimes require more than one session to allow the mind / body to reach the level of healing desired through bringing the entire system back into balance. I understand and believe that healing on every level requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefits of these healing sessions. I acknowledge my commitment to my healing process.


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Date*:


Name*:


Date of Birth*:


Signature (retype your name as you sign it)*:


Address*:


City*:


State*:


Zip*:


Phone*:


Email*:


Confirm Email*:



What health / life challenges are you facing right now?*:



List any treatments you are undergoing (traditional, alternative or complementary) along with any medications and vitamins or supplments you are taking*:



Comments & History (Family / Medical / Major Life Events, etc.)*: