Reconnective Healing® & The Reconnection® Client Intake Form
Please fill out and sign the Client Intake Form. The information you provide is confidential. I will contact you to book and confirm your appointment. Thank you!
First Name *
Please enter your First Name
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Last Name *
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Date of Birth *
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Gender *
Phone Number *
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Email *
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Address *
Number and Street Address
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City *
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State/Province/Region *
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Zip/Postal Code *
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Country *
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Services of Interest *
You may select more than one category.
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Is the first session you are booking an In-Person session or a Distance/Remote session? *
Please note that only Reconnective Healing and Transformational Counseling sessions are offered Distance/Remote. The Reconnection is always facilitated in-person.
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Date of Distance Session - IF APPLICABLE
If the session is a distance session, please indicate the date you would like to have it facilitated. I will contact you to confirm or reschedule based on my availability.
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Time of Distance Session - IF APPLICABLE
If the session is a distance session, please indicate the time (USA Central Time) you would like to have it facilitated. I will contact you to confirm or reschedule based on my availability.
Time
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Name of Other Person and/or Pet/Animal to Receive Initial Session(s) - IF APPLICABLE
If session is for another person or for a pet/animal, please enter their information in the space below (i.e. Full Name, DOB (if you know it), City, State/Province/Region, Country)
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May I include you in occasional email newsletters and updates? *
You may opt out at any time by simply emailing me your request.
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May I contact you at a later date to discuss the healing that you experienced? *
You may opt out at any time by simply emailing me your request.
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How did you learn about me, Daniela Simeone?
Method of Payment
Please select the method of payment for the initial session(s) you are requesting at this time. Payment will be collected prior to or at the start of your session.
Legal Disclaimer and Waiver (PLEASE CHECK THE BOX AND SIGN BELOW) *
Daniela Simeone, MA is a qualified Reconnective Healing Foundational Practitioner® and Reconnection Certified Practitioner® authorized by Dr. Eric Pearl and The Reconnection®, LLC to facilitate Reconnective Healing® and The Reconnection®. Please feel free to contact The Reconnection® at Info@TheReconnection.com to verify the practitioner’s credentials prior to your Reconnective Healing® sessions. Reconnective Healing® is not a medical treatment or procedure, and it is not a substitute for medical treatment. You are solely responsible for seeking your own medical advice and care. Daniela Simeone does not diagnose, treat, prevent or advise about any medical symptom, condition, illness or disease of any person when practicing Reconnective Healing® and The Reconnection®. Daniela Simeone, The Reconnection LLC and Eric Pearl do not make any claims, promises or guarantees to clients about the results of Reconnective Healing® and The Reconnection®.
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Your Signature: *
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