Mindfulness Private Client Registration Sheet

Private Client Registration Sheet
Class Selected
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Birthdate *

Month Day Year
How did you learn of the Mindful Living services? *

Newspaper Ad or Flyer Internet Family Member or Friend (Please provide detail below) Referred by (Please provide detail below)
Please provide detail regarding your referral source, family member, or friend.
My specific needs and intentions for participating in private sessions include: *
My personal goals and objectives include: *
My preference is to meet: *

Weekly Bi-Weekly Monthly
I understand the rate for services is $68/hour *

I understand and agree to the rate of service.
I understand that payment can be made by check (payable to Plumas Rural Services) or online by credit card. *

I understand and agree to the payment options.
Payment by check can be mailed to, or dropped off at:

Plumas Rural Services

711 East Main Street

Quincy, CA 95971

Online credit card payments can be made at the following link:

Mindfulness Private Session Payments
Should be Empty: