General Session Inquiry Form — Karen Kerns Polarity

Inquire about a Session

Please fill out the questions below so that I can be acquainted with your needs as we proceed with personal work. Thank you!

Name

First Name

Last Name

Where are you located? Are you inquiring about an in person or online session?

Is there a focus for the session? Please share what you might be looking to work with together:

Please share any medications you take or medical concerns you may have that are relevant to doing a healing session:

Please include any accidents; age and date

Falls; age and date:

Surgeries; age and date:

Do you have any questions for me? Is there anything else you would like me to know about you from the start?

Please reference your referral source:

Your Birth Date:

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