Confidential Client Case History & Intake Form
Intake Form for Energy Healing
Email address *
Name *
Address *
Phone number *
Date of Birth *
MM
/
DD
/
YYYY
Primary Concerns:
Medications/Remedies/Supplements & Reason for taking:
Significant Accidents/Injuries:
Please check any condition(s) that apply (past or present):
Please check any symptoms that apply:
Please check any areas below that you would like improvement on:
Below please describe what you would like to accomplish with these treatments:
*
Required
Solace Life Coaching & Alternative Therapies
www.restorewellness.online
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