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Birthday
Month
Day
Year
Preferred method of contact:
Email
Phone
Text
Type of location for desired service:
My in office location
Hospital
Hospice location
Nursing home
Assisted living facility
Which service are you interested in for this first session?
Tuning forks - In office
Tuning forks - mobile
Reiki - In office location
Reiki - mobile
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Date
Month
Day
Year

New clients...this screening form is required to ensure a good fit for us both.  Submission of this form DOES NOT guarantee acceptance, as I may need to consider location and suitability.  Simply fill out this form and I will be in touch with you soon thereafter.

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