PO Box 475 Southern Pines, NC 28388
USA
NC Phone: 1.910.692.5206 USA Atlanta, GA Phone:
1.404.242.9022 USA
NC Fax: 1.910.692.5103 Email:
Brent@BrentAtwater.com
Client Information Form:
Please return this to
the NC Office address by Fax, mail or email.
January 04, 2006
All information is strictly confidential & secure. Please fill this out
completely. Thank you
NAME:____________________________________________________________________
(last name first) first
middle nickname
BIRTHDATE:________________TIME:_____________PLACE:_____________
OCCUPATION:________________________________
Please send me your Picture, preferably a head shot so I can see your eyes
:___________
HOME
ADDRESS:_________________________________________________________
_________________________________________________________________
_________________________________________________________________
CITY: _______________________STATE:___________
PSTL CD:_________COUNTRY:__________
HOME PHONE:______________________ EMAIL HOME: _______________________
HOME PHONE 2:_____________________ CELL PHONE:_____________________
OFFICE PHONE:_____________________ EMAIL OFFICE:_______________________
Referred by:____________________________________________TU_________________
Alternative
contact:_______________________________________________
Phone:_________________________________________________________
When is a good time for me to call to discuss the details of creating your
artwork to
determine the size and price:
What do you plan to do
with your Healing Art?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Additional Comments:
___________________________________________________________________________
___________________________________________________________________________
Blogs for Alternative Healing thru Art That Heals (Healing
Art)
Paintings
That Heal™
Updates on this Art for Healing. Research trials, and research done for
healing art as an alternative healing modality. Client comments and testimonials.
Blog:
http://arthealingpaintingsthatheal.blogspot.com/
Site Feed:
http://arthealingpaintingsthatheal.blogspot.com/atom.xml
Blog:
http://spaces.msn.com/members/PaintingsThatHeal/
Site Feed:
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Healing Art for Children™
Blog:
http://healingartforchildrenartforhealing.blogspot.com/
Site Feed:
http://healingartforchildrenartforhealing.blogspot.com/atom.xml
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