Name: _________________________      Phone Number: ___________________

Location  & Specific Time Zone: ________________________________________

Date & Number of Sessions Purchased: ______________

Preferred Dates/Times of Appointments:  (Give 2-3 Possibilities)

____________________________  ____________________________  ____________________________

Specific areas of concern or things you would like me to know before we work together:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

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I will contact you within 24 hours of receiving your payment and this form to schedule our first session. Please email this form to me at solt.karen@gmail.com. Thank you!