Central Coast Quantum BiofeedbackSamantha Huston, Certiﬁed Quantum Biofeedback Specialist andLicensed Spiritual Health Coach

Full/Registered Name:

__________________________________________________Home Address:______________________________________________________________________________________________________________________________Date of Birth (or approximate):__________________ Time of Birth (if known):________Place of Birth:_____________________________________________Sex:__________Challenges and/or Goals:_____________________________________________________________________________________________________________________________________________________________________________________________

No. of organs removedNo. of times exercise per weekNo. of synthetic drugs usingNo. of major traumasNo. of allergiesNo. of major infectionsStress level from 1 - 10No. of pounds overweightGuardian Information

Name:________________________________________________________________Mailing Address (if different):_____________________________________________________________________________________________________________________Phone Number:_________________________________________________________Email Address:__________________________________________________________Referred by:__________________________________________Date:_____________

Quantum Biofeedback Animal Intake Form

www.SamanthaHuston.com 625 Main Street, Morro Bay, CA 93442 (805) 772-0584