Testimonial Form

Testimonial Form

I am so excited to hear your story! I love hearing how our work together has transformed your life- even in the slightest ways. Please complete the form below. Be sure to share descriptive details of results.
Clients Name*

First NameLast Name
Clients Age*
I am submitting a testimony as guardian/owner on behalf of my child, dependent or pet

Yes (please fill this form out for the client and sign your name at the bottom)
Todays Date*

MonthDayYear
Date
Date of first Session*

MonthDayYear
Date
Number of sessions completed
What issue was targeted in your Session(s)?
Symptoms, issues, concerns, etc.
Email
example@example.com
Phone Number
Please enter a valid phone number.
Testimonial Content:

I, the undersigned, hereby provide my testimonial regarding Emotion Code, session with Second Bloom. I grant permission to use my testimonial in various promotional materials, including but not limited to websites, social media, brochures, and other marketing channels.
Testimonial:
Please share your short story here. Be sure to share what changes you have noticed over time and how your Emotion Code sessions have improved your life since your first session.
At Second Bloom, I value the experiences and outcomes our clients choose to share. From time to time, we may request to use client testimonials for promotional or educational purposes, including but not limited to our website, social media platforms, print materials, or other public communications.

By signing below, you grant permission for any verbal or written feedback you choose to share about your experience to be used publicly without any direct disclosure of your personal identity or private information. We will ensure that all shared testimonials are presented in a way that maintains your confidentiality (e.g., using only your initials, first name, or a general description such as “Client”).

You are under no obligation to provide a testimonial, and you may withdraw consent for future use at any time by providing written notice via email to Healing@secondbloom.info.
Date

MonthDayYear
Date
Signature

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