Selacia's New Client Form

Selacia's New Client Form

Thank you for scheduling a session with Selacia.

NOTE: Your information will never be shared with outside sources. See below for privacy statement.
* Required fields for submission.

First Name*

Last Name*

Date

Address

City/Town

State/Province

Zip/Postal Code

Country

Home Phone

Daytime Phone

Email Address*

Best Timeframe for Sessions (Figured in California Pacific Time please.)

Age

Birthdate

Birthplace

How were you referred to Selacia?

Marital Status

Number of Children

Present Occupation

Occupation before illness (if applicable)

Spiritual or Religious Orientation

Hobbies or Leisure Activities

Present Physician

Have you ever experienced psychic or spiritual healing? When? With whom?


Please list all past major illnesses and surgeries and the year in which they occurred.

Are there any residual effects/what?


Briefly describe what particular condition(s) you would like to resolve and how long you have experienced them? Include with this both physical and emotional/mental conditions.

Of these conditions, what is your priority as you begin the healing work with Selacia?


What medications or nutritional supplements do you take regularly and for what purpose?


Briefly describe what you have done (via conventional and alternative means) to heal your priority condition. Also, describe what form(s) of personal transformation work you typically do to help yourself grow and to de-stress (e.g. meditation, a healing process, journaling, body work).

For Astrology Readings Only
This information will be used to calculate your solar return, the chart that will indicate the energies you have set up for your current year depending on where you spent your birthday. The energies you have to work with in any given year can vary significantly depending on the location where you spend your birthday!

Exact time of birth:

Name of a large city nearest your birthplace.
(If you were born in a small town, please include the name of the nearest large city.)

Where do you plan to spend your next birthday?
(If your birthday was within the last 3 months, please indicate where you spent it.)

If you would like to join Selacia’s opt-in Mailing List, please indicate your interests below. In the future, you will receive periodic emails specific to your interests. Many times, announcements are made only to Selacia’s email list, so this is the best way to be kept informed. You can choose, at any time, to unsubscribe, or to receive less or more information.
Selacia's Mailing List categories:
Books by Selacia
Channeling evenings
Crystals and crystal healing
DNA intuitive healing
Nonphysical world
Nutrition and rejuvenation
Pets
Teleclasses
Wesak celebrations

Comments:

REQUIRED FIELD:
For security purposes, before you Submit, please enter the code shown in the image below. It is recommended that you first print out this form so that you can have a copy for reference.

back to DNA Intuitive Healing Sessions (and DNA Activations, Core Belief Repatternings)

back to Channeling Sessions with The Council of 12

back to Pet Healing Sessions (and Animal Communication)

back to Crystal Journey Sessions

back to Astrology Reading Sessions

Privacy Statement
Privacy is important to us; therefore, we will not sell, rent, or give your name and address to anyone. You may choose, at any time, to unsubscribe from Selacia’s Mailing List.

© 2000-2007,
Communication for Transformation Group
All rights reserved.

First Name*
Last Name*
Date
Address
City/Town
State/Province
Zip/Postal Code
Country
Home Phone
Daytime Phone
Email Address*
Best Timeframe for Sessions	(Figured in California Pacific Time please.)
Age
Birthdate
Birthplace
How were you referred to Selacia?
Marital Status
Number of Children
Present Occupation
Occupation before illness (if applicable)
Spiritual or Religious Orientation
Hobbies or Leisure Activities
Present Physician
Have you ever experienced psychic or spiritual healing? When? With whom?
Please list all past major illnesses and surgeries and the year in which they occurred.
Are there any residual effects/what?
Briefly describe what particular condition(s) you would like to resolve and how long you have experienced them? Include with this both physical and emotional/mental conditions.
Of these conditions, what is your priority as you begin the healing work with Selacia?
What medications or nutritional supplements do you take regularly and for what purpose?






Briefly describe what you have done (via conventional and alternative means) to heal your priority condition. Also, describe what form(s) of personal transformation work you typically do to help yourself grow and to de-stress (e.g. meditation, a healing process, journaling, body work).
For Astrology Readings Only This information will be used to calculate your solar return, the chart that will indicate the energies you have set up for your current year depending on where you spent your birthday. The energies you have to work with in any given year can vary significantly depending on the location where you spend your birthday!
Exact time of birth:
Name of a large city nearest your birthplace.	(If you were born in a small town, please include the name of the nearest large city.)
Where do you plan to spend your next birthday?	(If your birthday was within the last 3 months, please indicate where you spent it.)
If you would like to join Selacia’s opt-in Mailing List, please indicate your interests below. In the future, you will receive periodic emails specific to your interests. Many times, announcements are made only to Selacia’s email list, so this is the best way to be kept informed. You can choose, at any time, to unsubscribe, or to receive less or more information. Selacia's Mailing List categories: Books by Selacia Channeling evenings Crystals and crystal healing DNA intuitive healing Nonphysical world Nutrition and rejuvenation Pets Teleclasses Wesak celebrations Comments:
REQUIRED FIELD: For security purposes, before you Submit, please enter the code shown in the image below. It is recommended that you first print out this form so that you can have a copy for reference.