Client Registration Form
Thank YOU for choosing YOU. Your healing has already begun.
Please fill in as many of these questions possible, if you'd prefer to leave any blank that is fine as well.
This is your process but I advise you to give as much information as possible for the biggest obtainable energy shift and profound healing.
Phone/ Mobile Number
Date of Birth
How would you like to receive your first call?
Zoom - You will be sent an link via email to click and connect to the call
Medical History (including any current medication)
What is the main thing bothering you in your life presently
How do you think this is blocking you
Put one goal you would like achieved as an out come of this treatment
If not obvious, please state below how you will know when your goal has been reached
Please tick to give your consent to the storing and using of your personal information, for the sole purpose of us getting back in touch with you. All information is confidential and never shared with 3rd parties. Thank you.
I give consent
I acknowledge that Clare Chater is a qualified shamanic practitioner and not a doctor or health care professional and that I should not ignore any advice given by my qualified doctor the NHS or my private health care professional. I understand that healing is complementary and to be used alongside professional health care and advice, not instead of. I alone am responsible for the well-being and perception of my life. I take full responsibility for my individual experience and outcome associated with all healing and beyond. I acknowledge that this healing’s intention is to provide a sacred space of trust and privacy for my healing and personal growth. I recognise that the energy healing which I have agreed to receive is highly sought after and a gift. I have carefully and thoroughly read and understood this agreement. I certify that i am 18 years of age or older. Under no circumstances will Clare Chater be held responsible for my actions or circumstances. Heirs, guardians, legal representatives of/and Clare Chater or PASH CEREMONY hereby and forever release, waive, and discharge any claims against Clare Chater or PASH CEREMONY, and any of their associates, affiliates, or family. I am aware that by ticking this box is confirming as my signature and I am agreeing to the aforementioned statements. I accept these terms with gratitude for my individual free will choice.
I tick this box to confirm my agreement.
Send me a copy of my responses.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service