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 on my website without using any personal names or information, if I think it would be of interest or help 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