Hands On Healing Form


	Personal Information
	First and Last Name
	Email Address
	Phone Number
	Physical History
	Do you have physical trauma you are dealing with? Yes No
	If yes, please give a brief description in the box below

	Therapy History
	Are you currently working with a therapist? Yes No If yes, how long?
	Have you worked with a therapist in the past? Yes No If yes, how long?
	Please give a brief description of topics discussed in your therapy in the box below

	Choose which therapy you are interested in
	Phoenix Rising Therapy Yoga Reiki Therapy Yoga