CaringHandsOfDuPage.com

 www.caringhandsofdupage.com

Business Phone number: 630 890 7767 Faxnumber:630 653 8159

Today's Date:

First and Last Name:

How did you hear about Caring Hands/Sarvaga Institute?

Birth Date:

E-mail address:

Contact Phone Number:

Occupation:

Employer:

Employer Address:

City, State:

Switchboard Phone Number:

What is your marital/relationship status?

What do you intend to accomplish out of your participation in the Caring Hands session/Sarvaga Institute program?

Do you have any health concerns? If so, please indicate:

Do you take any medication? If so, please indicate:

Scheduling Session

Tantric Education Session:

Do you have any knowledge of Tantra?

Do you know what Chakra's are?

What would you like to create in your life or a particular area in your life?

Have you seen a Tantric Practitioner in the past that maybe used as a reference?

All information will remain confidential and discrete measures will be taken when verifying employment.

In submitting this form you agree and give permission to the use of the healing modalities and

education that Caring Hands/Sarvaga Institute offers. Further more you; release Caring Hands/Sarvaga

Institute and owner of any legal reasonability for you physical, mental, or spiritual well being. All services

are offered in good faith and offerings of monitory or exchange work for services rendered is for the

time and expertise of the practitioner/educators. ___________(Initials)

Namaste', Mary

Signature_________________________________________

Date: ___________________________