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?
*
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