CLIENT INFORMATION & CONSENT (Confidential)

Janine Mateparae is a certified practitioner of Havening Techniques.

Havening Techniques is a registered trade mark of Ronald Ruden, 15 East 91st Street, New York. www.havening.org

Name *
Date of Birth *
Email *
Phone Number *
Address *
Occupation *
Name of GP / Medical Practitioner *
List any current medications and the condition it was prescribed to treat (include homeopathic)
*
Any previous or current therapy?
*
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy