Integrated Trauma Treatment

Healing the Past. Building the Future. Supporting Whole-Person Recovery

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Book an Appointment and Release Form

Use the form below to book your appointment and fill out the release information. I look forward to working with you.

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Name *

First

Last

Email *

Phone Number *

Date of Birth (MM/DD/YYYY) *

Address *

I would like to book an appointment: *

In Person (Pinehurst, NC)
By Phone
By Zoom

I would prefer a time: *

During the day during the week (9 am to 5 pm EST)
During the evening during the week (5 pm to 9 pm EST)
On the Weekend (Saturday between 10 am and 5 pm EST)

My time zone is: *

If you also live in the Eastern Standard Time zone, please put "same" or EST. If another time zone, please indicate which one so we can arrange the time to work together accordingly.

List any serious illness, accidents, or trauma & dates

Please Check any health conditions you are experiencing:

Thrombosis
Phlebitis
Epilepsy
Pacemaker
Cancer
Heart Condition(s)
Pregnant

Describe your birth experience

Who is your Health Practitioner and what condition are they treating you for?

List your medications

Who Referred You?

Emergency Contact:

Emergency Contact Phone Number:

Digital Signature (type full name to sign) *

Date of Signing (MM/DD/YYYY) *

I understand Lisa Sullivan is not an M.D, D.O, or N.M.D. and that she is a trained Reiki Practitioner trained in Trauma Release. Any treatment Lisa Sullivan provides is intended to compliment medical treatment and is not a substitution for medical care. I agree to cancel any appointment 48 hours in advance or pay the full appointment fee unless the cancellation is the result of an emergency. I received a copy of Lisa’s training & Contact information.

would Emergency Health

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