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Sound and Energy Healing
Leslie Schroer
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Intake Form
Client Information
First name
*
Last name
*
Email
*
Phone
*
Date of Birth
*
Month
Day
Year
Emergency contact name
*
Emergency contact phone
*
Health & Preferences
Is the use of essential oils acceptable?
*
Yes
No
Do you have any known allergies?
*
Yes
No
If yes, please list:
Are you photosensitive or have you ever had or are you currently experiencing issues with flashing lights or seizures?
*
Yes
No
If yes, please list:
What are your goals for pursuing this type of treatment?
*
How did you hear about us?
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