New Client Registration Form

Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I'm interested in

Reiki + Intuitive Healing

Yoga

Pilates

Meditation

Sound Healing

Cacao Ceremonies

Roll & Release (Myofascial Release)

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

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About you

Please tick anything that relates to you

Use alot of handheld devices/computers

Spend more than 2hrs a day sitting or at a desk

Exercise regularly

Exercise seldomly

Meditate regularly

Carry stress in your body

Low Energy / Fatigue

Low Iron

Digestive Issues

Low Blood Pressure

High Blood Pressure

Headaches

Contagious Disease(s)

Anxiety / Fear

Depression / Grief

Negative self-talk

Neck or Joint Pain

Heavy / Irregular Periods

Experienced Trauma

Are a spiritual person

Have participated in Yoga before

Have had a Reiki or similar healing done before