Client Information Form - In-PersonPlease tell me what your session goal is related to: Name*FirstLastEmail address*Date & Time of BirthMonth | Day | Year | Time (AM/PM)Place of BirthCity | Province/State | CountryCanadian Resident*YesNoCheck the boxes that apply to you and add a brief explanation in the box below, if neededFatigueI wake up tiredsurviving rather than thrivingdragging myself to get through the dayno interest in lifepregnantDigestioncrampsindigestionnauseaconstipated / diarrheaGERDhiatus herniapregnantEmotionalnervousoverwhelmedanxioushyperworriedsadnessfearfulpregnantAre you human?*SubmitThis field should be left blank
