Client Intake Form

Self Referencing
Self Referencing

Thank you for taking the time to take care of YOU. Please Complete the form below before your session. All information will be kept confidential.

    I understand and agree that I am individually responsible for my own life and it’s unfolding.

    As an expression of my responsibility I am seeking assistance with the beliefs that
    manifest my reality, but the actual manifestation of that reality is up to me. I’m committed to my session(s).

    I also understand that cancellations or rescheduling of appointments requested less than 24 hours prior to my session time result in a forfeit of that session.