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PHH at the Heart Counseling and Wellness Consent & Liability Waiver for CAM Therapies
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Full Name
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Date of Birth
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Mailing Address
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Best contact number
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What is a good email address for you?
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What is your Occupation?
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Emergency Contact Person - Name and Phone
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Are you currently under the care of a medical Physician?
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No
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Are you currently under the care of a mental health professional?
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No
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Are you currently taking any medications and/or supplements? If yes, please list them
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Do you have any allergies?
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If yes, please is allergies here.
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Have you ever had the following treatments or attended the following?
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Massage Therapy
CranioSacral Therapy
Reiki/Energy Work
Yoga Class
Meditation Class
Ecotherapy/Nature Therapy
Other:
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