Client Registration Form

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Peace Valley Healing Center

Client Registration and Information

(all information is kept strictly confidential)

 

Name:__________________________________________________Male________ Female_______Date:____________

 

Address:__________________________________________________________________________________________

 

City:___________________________________State:______________Zip:_________________

 

Daytime Phone:____________________________Evening Phone:_________________________email________________

 

Date of Birth:______________________________ Occupation:____________________________________

 

Preferred Appointment Day and Time:____________________________________________________________________

 

Referred by: Name:_________________________________________________

 

Ad____________Brochure______________Sign:______________Other:________________________________________

 

 

Are you currently under medical or psychiatric treatment for any disease or disorder?

 

Please describe_______________________________________________________________________________________

 

 

Please answer the following questions as completely as possible.

 

Why are you here today?________________________________________________________________________________

 

____________________________________________________________________________________________________

 

 

Have you ever received any form of energy or alternative therapy before? (ex: Reiki, Flow Therapy, Shiatsu):____________

 

____________________________________________________________________________________________________

 

 

Describe your response to former therapy physically and emotionally:_____________________________________________

 

_____________________________________________________________________________________________________

 

 

Are you currently satisfied with your physical health and wellness?_____________________________________If not, what

 

would you like to change?________________________________________________________________________________

 

 

Please read and sign the session consent form and retain the copy of PVHC treatment policy for your information. Thank you!

 

 

 

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Copyright © The Center of Being, Inc                                           
Last modified: January 30, 2012