Client Information Sheet

For Resonance Repatterning,  Reiki Treatments,
Astrology & Card Readings with Alicia Sinicrope

Full Name (At Birth):

Birth Date (month/day/year):

Birth Time:

Birth Place:

Current Phone Number:

Current Email:

Would you like to receive information via email?:

Current Address:

Is there anything you would like to focus on?

I Have Read and Understood the Resonance Repatterning Clients Rights Information (2 pages)  and take full responsibility for my own well being and understand that for all medical or psychological concerns I am responsible for consulting the health care practitioner(s) of my choice.

Signature_____________________________________

Print Name____________________________________

Date_____________