Client Information Form - Single SessionName*FirstLastEmail address*Mobile PhoneDate & Time of BirthMonth | Day | Year | Time (AM/PM)Place of BirthCity | Province/State | CountryCanadian Resident*YesNoCheck the boxes that apply to youFatigueI wake up tiredsurviving rather than thrivingdragging myself to get through the dayno interest in lifepregnantDigestioncrampsindigestionnauseaconstipated / diarrheaGERDhiatus herniapregnantEmotionalnervousoverwhelmedanxioushyperworriedsadnessfearfulpregnantPlease tell me what your session goal is related to:Permission*By submitting your information you are giving Kerryleegh permission to provide you Energy Medicine services that will energetically intend to facilitate physical transformation. Disclaimer*These services are meant to compliment your quality of life rather than replace advice of your medical professional. Energy Medicine is neither a diagnosis nor personal counseling. This is an ENERGETIC intuitive consult, based on the concepts of energy interpretation and must be handled in such a manner. The intention is to provide Energetic services to support you achieving your goals, restore energetic balance and harmony. Energy Medicine is not yet claimable on insurance. Are you human?*SubmitThis field should be left blank
