Resonate With Life Intake Form
Resonance Repatterning Client Information
Your Name *
What are your pronouns?(ex. She/Her, He/Him, They/Them, etc.) *
Birthday
MM
/
DD
/
YYYY
Email *
Address
Phone *
Your preferred method of communication (appointment reminders, appointment follow-up, etc): *
Identity/ies You Would Like Me to Know About (gender, race, ethnicity, sexual orientation, disability, etc)
Accessibility Needs I Should Know About (hearing, visual, mobility, etc)
Nearest Contact
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