Coaching Application Form

Give the gift of healing to yourself or a loved one.

This is an opportunity to book a 50 minute appointment with one of our therapists.


Skype or Phone Session Packages Available

Costs are subject to 5% GST


For Non Canadian Residents all pricing is in US dollars
Please select the session you are interested in. Once you purchase the session(s), we will send intake documents for you to complete and submit. Arrangement will be made for one of our coaches to connect with you.
 
Last Name:
First Name:
Address
Suite/Apt no.
City
State/Province
Zip Code
 
Home Tel:
 
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Mobile:
 
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Email
Date of Birth
 
Sex

Payment Information

* All Fields Are Mandatory to Complete the Application Form
Billing Address
Is your billing address same as your current address?
Yes, same as my address filled in above
No, different Address
If No, please provide your billing address
Payment Method
  • The three digit security number imprinted on the signature panel on the back of your Visa or MasterCard credit card.

    This three-digit security number is a tool used to help prevent fraudulent use of credit cards. It helps to validate that the customer has a genuine card in his / her possession for Internet or mail order transaction.
I understand that should circumstances prevent me from keeping an appointment, a minimum 24 hours notice is required for any change. I understand all fees are non-refundable and should I miss a session without providing required notice I understand no credit for the missed session will be provided.