New Client Inquiry

First Name

Last Name

Mobile Phone

Home Phone

Email

Address

City

Country

Province / State

Postal / Zip Code

What are you interested in?

Craniosacral Therapy

Integrative Massage

BodyMind Bridge Hypnotherapy

I'm not sure yet, help me choose

How would you like to pay?

Private Pay (cash, card, or HSA/FSA)

I'd like to use insurance

If you would like to use insurance, which company and plan? (I'm accepting only a limited number of new insurance clients. Let me know your plan and I'll let you know whether I can bill it.)

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What's bringing you in? (A few sentences is plenty: what’s going on, and how long it’s been going on.)

What would you like to feel or be able to do after our work together?

How did you hear about me? (If a current client referred you, I’d love to know who)

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Anything else you'd like me to know, or questions for me?