Energy healing( including hypnotherapy)session client form

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Thank you for signing up! Mayumi will be contacting you within few hours. If somehow you do not hear from Mayumi, please contact at mayumi@beautywithinskincare.com or+1 443-987-4140.

1: Name *

1: Cell phone number *

3: Email address *

4: Address *

5: Preferred contact method *

Phone

All

Required

6: May we add you our occasional email? *

Yes

Required

7: Where did you hear about this service? *

8: What is your reasoning for seeking energy healing session?( Including hypnotherapy) *

8: It is essential that client understands that no energy healing, therapy including hypnotherapy can be accepted for replacement for any prescribed or necessary medical treatment, but is best used as complementary treatment. Energy work practitioners are not able to diagnose or medically treat any illness or condition. Typed signatures are accepted as your eSignatures on this form. *

Read and fully accepted

Required

8: Print name as signature *

8: Today's Date *

YYYY

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