New Client Form

The amount of space available for each answer seems limited on the form below, but there's actually plenty of space for a complete description of your issue...just keep typing and the form should keep up. If you have any problems, though, feel free to call or send an email to your coach (for contact info, click here). For 1-10 rankings, 10 is most, 1 is least. Even if you feel like you don't know the answer, go ahead and guess. Please submit this form at least 24 hours in advance of your first appointment.

Thank You!

New Client Form
Email:
Full Name:
Coach Preference (Bill, Lily, or don't know):
Street Address:
City:
State or Province:
Zipcode or Postal Code:
Country:
Phone Number:
Are you under a Physician's care?:
Currently taking any medications?:
Do you take any supplements?:
Description of Problem(s):
Current or frequent symptoms:
Goals or Objectives for our work together:
Injuries/ Accidents/ Traumas/ Life changing events:
Year of Birth:
Rate your level of physical flexibility (1-10):
Rate your current/normal pain level (1-10):
Do you sleep well? Get enough sleep?:
Are you dealing with depression? Rate severity (1-10):
Are you dealing with anger? Rate severity (1-10):
Are you dealing with anxiety? Rate severity (1-10):
Are you dealing with PMS symptoms? Rate severity (1-10):
Are you dealing with sexual dysfunction or dissatisfaction? :
Other Therapies Tried:
When Did Everything Start:

By clicking the "Submit" button below, I acknowledge that I am aware that neither Lily Alexander nor William Cael are medical doctors or licensed health professionals; they offer consulting services as coaches and ordained ministers. I agree to take full responsibility for my physical and mental well being and utilize common sense and seek proper medical care whenever the need arises. I understand that my consultations with Lily or Bill may utilize techniques like EFT which have produced remarkable clinical results, but which are still considered experimental and generally unrecognized by the medical community. I further understand and agree that Lily and Bill do not claim to diagnose or treat any illness or disease.

Testimonials

"I needed to speak to groups for my new job, but I was terrified. I was sweating, forgetting my presentation, and so tense I'd get a headache - it was horrible. I had to get over my fear and EFT was so easy. After my session I would practice and visualize at home for about a week. Then by the time I had my presentation, I sailed through it. Whew! Thanks so much." B.W.