Pre-Session Questionnaire

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address

City

State/Prov

Zip/Postal Code

Country

Home Phone*
Home Phone*

Birth Date

Occupation

Educational Background

Relationship Status

Health Problems?

Addictions / Habits / Cravings? Please describe:

Are you familiar with EFT?

	Yes
	No

Matrix Energetics?

	Yes
	No

Reconnective Healing and The Reconnection?

	Yes
	No

Brief Description of Desired Outcome or Intention for Session

Please enter the word that you see below.