Electronic Signature
First name  *
Last name  *
Mailing Address  *
City  *
State  *
ZIP/Postal Code  *
Country
E-mail  *
Today's Date (format xx/xx/xxxx)  *
I certify that I am 18 years old or over and have read and received a written copy of this Disclosure Form. I understand the contents of this form and voluntarily choose of my own free will to receive the energy treatments as described above. [Type YES in  *
I certify that this is my 1st experience with Theta Healing [YES or if not, advise history]  *
I fully understand and can speak the English language. [Type YES in box to right]  *
I fully understand that if I purchase a session or session package, there are no refunds. Sessions expire one year after purchase date. Paid sessions can be transfered if you are unable to complete. [Type YES in box to right]  *
Signature: [type your full name]  *
1st Session Date/Time
Phone number to reach you at for your session (include area code):  *
I have watched the pre-requisite video.  *
* Required fields