New Client Form

Dec. 3, 2016

I would like to learn more about you and how I can assist you in achieving the peace and balance in your life. Please complete and submit the form below to get started on making a difference in your life! Please be as detailed as possible as all information will be kept confidential.  I look forward to speaking with you soon.

 

 

 

First Name ________________________________

Last Name ________________________________

Privacy Notice:  We respect your right to privacy. Your information will not be sold or otherwise distributed, and will be kept in the utmost of confidentality.

Email   ___________________________

Street Address  __________________________________

City   _______________________________________

Area/Zip Code ___________________________________

Province/State ___________________________________

Primary Phone Number ______________________________

I Perfer to be contacted by -email _________ phone _____________ Mail ___________

What is the best time to contact you? Morning ___ Afternoon _____ Evenings ________

Please detail the areas that I can assist you in claiming peace and empowerment. Be as Detailed as possible.

What service would you like to receive?

 

 

 

Why do you wish this service?

 

 

 How Did you learn about us?

 

 

Cancellation Policy : 24 hr notice must be given to cancel any service. We understand things happen and life is full of surprises. If 24 hrs is not given 1/2 the fee will be charged.