Start Here
About
Services
Scheduler
Shop
My account
Community
Events
Blog
Menu
Start Here
About
Services
Scheduler
Shop
My account
Community
Events
Blog
NEW CLIENT FORMS
Name
Date Of Birth
Email
Phone
Address
Do Phone # receive text
OK to contact me by text message with information pertaining to my appointment
Message
Receipt, Understanding and Acceptance
Payment Policy: Full payment is required at the time of service. Payment plans are available for clients with financial hardship. Lavender Solutions offers package pricing which discounts the regular price per visit. Please note the only acceptable forms of payment are; Debt / Credit Card, Venmo, PayPal, Cash
Receipt, Understanding and Acceptance
I certify that Lavender Solutions Practitioner does not claim to cure any illness or disease with Brain Working Recursive Therapy (BWRT), Herbs and Nutrition, and / or Mentoring.
Select Response
Yes - I am currently under the care of a Medical Practitioner for any mental health issues.
No - I am not currently under the care of a Medical Practitioner for any mental health issues.
Any form of trauma
Post-traumatic stress disorder
Sexual abuse
Self-esteem issues
Issues of rejection
Trust issues
Releasing negative emotions
Stress and anxiety
Panic attacks
Increasing motivation
Anger
Infertility Issues
Habits, including smoking, gambling, eating, drinking, shopping etc.
Fears, including fear of failure
Self-confidence issues
Improving Self-Worth
Phobias
OCD (Obsessive compulsive disorder)
Relationship problems
Grief
Depression
Guilt
Goal Setting
Signature
Date
Submit
