Customer Information Form

Name *

First

Last

Email *

Phone *

Preference for contact *

call
text

Age *

Religious/Spiritual Affiliation/Beliefs? *

Marital Status: *

Number of Children and ages: *

What days of the week and times of the day are ideal for your session(s) *

Days & Time Range

Which Session are you interested in?

PSYCH-K-in person or long distance
CranioSacral — in person only
Total Body Modification (TBM) — in person only
Mentoring/consultation— usually long distance, but in-person MAY be possible.

Main reason you are seeking a Craniosacral session, in one or two sentences. *

Main reason you are seeking a TBM session, in one or two sentences. *

Main reason you are seeking a mentoring/consultation session, in one or two sentences. If you prefer not to state anything specific here, say so. *

PSYCH-K Questions- Session Type Desired *

In Person
Long Distance

Give one sentence that best describes your relationship with your parents~ Mother: *

Give one sentence that best describes your relationship with your parents~ Father: *

List all techniques, processes or therapies you have experienced to date. *

What area(s) of life are you seeking to transform with PSYCH-K®? *

What do you think needs to be “true about you”, to have the life you want? *

Are you experiencing any physical conditions? (allergies, illnesses etc.) *

Are you currently taking any prescriptions or drugs? *

**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) and agree to use my purchased time within 6 months. I also understand sessions are non-refundable and cancellations or rescheduling of appointments requested less than 24 hours prior to my session time result in a 30-minute deduction from my available balance. *

Signature

Date / Time

Date

Time