Claire M. Schwartz BA, Reiki Master Teacher, Spiritual Counselor, Interfaith Minister Certified Professional Coach,Grief Healing Expert
Emergency Contact - Name/Number:
I, the undersigned, understand and acknowledge the following:
Are you currently taking any prescription medication?
Are you currently experiencing anxiety, panic attacks or have any phobias?
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)
I hereby affirm that I have answered all medical & psychological questions completely and honestly.