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Client Information Form

Please fill out the information below as best you can. It will help us to help you!

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Top 5 Concerns

List your top five problems or issues starting with the problem or issue you would like to be rid of the most. These could include any health or emotional problems, relationship issues, (past or present) disabilities, inabilities, work or money related issues, and anything else that might be significant.

Message

Major Life Traumas

List any major traumas you have experienced in your life along with the age that it happened. Feel free to elaborate if you feel it would be helpful to us.

Consent

By selecting this option, you consent to receive services as described and rendered by a Certified Staff Practitioner.

Yes, I Consent

Please confirm payment has been submitted. Payment Method: Zelle using phone number 346-528-9500. Sessions are $90. Children under the age of 12 are $45 per session.

Testimonials

Amelia had relief from nightmares after one session
Beverly was relieved of the symptoms of a Urinary Tract Infection after two sessions.
Carol had relief from a chronic runny nose after one session.
Daren had 80% improvement in distorted vision after 5 sessions, and is still working toward 100% improvement.
Ernest has released long held anger at a relative after one session.
Frank had enough confidence after 6 sessions to make a career move.
Toddler G. has recovered from waking up on a nightly basis, crying in terror.

Work With Me

Client Information Form

Thank you for completing the Client Information Form!

To finalize your booking, please select a convenient day and time for your 45-minute appointment and send your payment via Zelle (346) 528-9500

SCHEDULE APPOINTMENT

If you have any questions or need assistance, feel free to reach out.

Amelia had relief from nightmares after one session

Beverly was relieved of the symptoms of a Urinary Tract Infection after two sessions.

Carol had relief from a chronic runny nose after one session.

Daren had 80% improvement in distorted vision after 5 sessions, and is still working toward 100% improvement.

Ernest has released long held anger at a relative after one session.

Frank had enough confidence after 6 sessions to make a career move.

Toddler G. has recovered from waking up on a nightly basis, crying in terror.