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Theta Healing LA Private Session Registration Form
Name
*
First
Last
Email
*
Phone Number
*
Have you done a Theta Healing private session with Brent before?
No, I am a new client
Yes, I have worked with Brent before
Are you eligible for the Formula for Miracles VIP Club discount?
No, I am not
Yes, I have been in the VIP Club for more than 30 days
Please enter your VIP Club username here:
How do prefer to connect with Brent for your session(s)?
Telephone
Skype
In-Person
How do you prefer to pay? (When your session is scheduled, you will receive an email invoice with a link to pay online via credit card or PayPal. Or, you may also send a check or money order, or bring cash for an in-person session, or provide your credit card information to Brent during your session.)
Credit Card (Visa/Mastercard/Discover/Amex)
PayPal
Check/Cash/Money Order
I prefer to be contacted by:
Email
Phone
Skype
What kind of session(s) would you like to schedule?
I'm not sure - please contact me!
Package of five 30 minute sessions ($597)
30 minute First Class private session (flexible scheduling, $200)
60 Minute First Class private session (flexible scheduling, $400)
30 Minute private session ($150)
60 Minute private session ($300)
30 Minute private session, VIP Club member ($120)
60 Minute private session, VIP Club member ($240)
When are you available? (Write "ASAP" if you are flexible and want the soonest possible appointment time.)
Skype Username (optional)
Do Not Fill This Out
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