New Client Registration Form

    First and Last Name (required)

    Date

    Home Phone

    Cell Phone

    Skype Name (if you have one)

    How shall I contact you for our session?
    Home PhoneCell PhoneSkype

    Your Email (required)

    Address

    City

    State

    Country

    Zip Code

    Your Time Zone

    Occupation

    Age

    SingleWith Partner

    How did you hear about my practice?

    Would you like to receive my free newsletter that offers huge discounts on sessions and information on intuitive classes, spirituality, health and sustainability?

    May I call or email you after your session to see how you are doing?
    YesNo

    May I transcribe our session for public display without using any personal names or information, if I think it would be of interest or beneficial to others?
    YesNo

    You will receive a $10 discount on your next session for referring a friend to me.

    All payments are due in advance at the time the appointment is made.

    What type of session would you like to receive?
    Energy ReadingEnergy HealingEnergy Reading and HealingIntuitive Counseling

    Would you like your session to be recorded?
    YesNo

    What is your topic or question for this reading?

    If this is a medical reading, please list any current illness, pain or symptoms that you would like addressed.

    What is your desired goal for this session?

    For medical readings please answer these questions:

    Weight

    Height

    How often do you exercise?

    Prescription Medication Used For

    Do you eat/drink:

    Alcohol
    NeverMonthlyWeeklyDaily

    Soda
    NeverMonthlyWeeklyDaily

    Caffeinated Coffee
    NeverMonthlyWeeklyDaily

    Black or Green Tea
    NeverMonthlyWeeklyDaily

    Wheat
    NeverMonthlyWeeklyDaily

    Bread
    NeverMonthlyWeeklyDaily

    Cookies/Cakes
    NeverMonthlyWeeklyDaily

    Chocolate
    NeverMonthlyWeeklyDaily

    Natural Sugar Additives (Honey, Fructose Corn Syrup, Agave, etc.)
    NeverMonthlyWeeklyDaily

    Artificial Sweeteners (Aspartame, Sucralose, Neotame, Saccharin, etc.)
    NeverMonthlyWeeklyDaily

    Red Meat
    NeverMonthlyWeeklyDaily

    White Meat
    NeverMonthlyWeeklyDaily

    Dairy (Cheese, Eggs, Milk, Butter)
    NeverMonthlyWeeklyDaily

    Grains
    NeverMonthlyWeeklyDaily

    Cigarettes
    NeverMonthlyWeeklyDaily

    Drugs
    NeverMonthlyWeeklyDaily

    (Required) I agree to the above policies and understand that Robin Sage is not a doctor and that the information provided in this reading is not to be substituted for the advice of my primary health care physician.

    (Required) Signature