Freedom Community Clinic Fall Holistic Healing Clinic Service Sign-Ups
Tuesday evenings
October 15 - November 19
6:30-8:30pm
East Bay Community Space
55th & Telegraph

We prioritize services and space for systems-impacted communities, including but not limited to POC + WOC + LGBTGNC + folks of low-income, disability, etc.

IMPORTANT!
**PLEASE FILL OUT A NEW FORM FOR EACH DATE AND SERVICE** (for example -- if you would like to receive acupuncture and herbal medicine consultations on the same date or on different dates, please fill out a new form for each request).

Healing services are 30 min each.
Healing circles are 1.5-2 hours and will last for the full duration of the clinic (6:30-8:30pm).
All services and healing circles are offered at sliding scale rates: $10-$100. We accept cash and Venmo.

If you come early, you are welcome to hang out/study/relax in our healing corners, enjoy tea/light refreshments, and add/provide love offerings to our community healing art wall and altar.
Name *
Your answer
Phone Number *
Your answer
E-mail *
Your answer
Age *
Your answer
Do you have any special needs, medical conditions, or sensitivities to be aware of? *
Your answer
If you identify as being part of "systems-impacted communit(ies)" (e.g. POC, WOC, of low-income, of disability, etc), please indicate which communities below.
We prioritize services+space for systems-impacted communities.
Your answer
I agree to the responsibilities outlined in our "Practitioner and Recipient Responsibilities Form" found here: https://bit.ly/30Tsu1R *
I grant permission to Freedom Community Clinic to use my image (photographs/video) in media publications (e.g. social media, brochures, flyers, etc.)
This is not required to receipt of services. However, your participation would help us spread the word of our services to others! Please feel free to reach out to us with any questions/concerns.
Which date would you like to receive a service/participate in a healing circle? *
**PLEASE FILL OUT A NEW FORM FOR EACH DATE AND SERVICE** (e.g. if you would like to receive acupuncture and herbal medicine consultations, please fill out a new form for each request). Healing services are 30 min each. Healing circles are 1.5-2 hours and will last for the full duration of the clinic (6:30-8:30pm). All services and healing circles are offered at sliding scale rates: $10-$00.
What service are you interested in receiving?
What is your FIRST CHOICE time slot for your healing service consultation? *
Those interested in participating in healing circles do not have to fill this question out. Please provide us with up to 3 choices to accommodate everyone who is interested in receiving services.
What is your SECOND CHOICE time slot for your healing service consultation?
What is your THIRD CHOICE time slot for your healing service consultation?
Before each clinic starts, we gather as a community for an opening ceremony and love offering from 6:15-6:30pm. Will you join us then?
Questions, comments, concerns?
Your answer
How did you hear about us?
Your answer
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