Intake Form


Please fill out the intake form below prior to our first visit.


Name *
Name
What is your birthday? *
What is your birthday?
What is your address? *
What is your address?
May I add you to my newsletter? *
Have you experienced Healing Touch, EFT, Emotion Code or other energy therapy before? *
Living situation: Married / Partner / Single *
Are you under the care of a doctor, psychotherapist, counselor or other health care practitioner at this time? *
Are you currently taking any medications? *
Please indicate which of the following symptoms/concerns are areas of distress in your life: *
By submitting this Intake Form, I have read the Consent and Personal Responsibility as outlined on harmony-restored.com. *