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Client Intake Form

Name (First and Last)*

Home Address*

Email Address*

Phone Number*

Referred by (or how you found me)*

Service Requested*

Dr. Eric Pearl has authorized Rob Koenig to facilitate Reconnective Healing and the Personal Reconnection. Rob Koenig makes no claims, promises or guarantees. Dr. Pearl and anyone associated with his work, inclusive but not limited to Reconnective Healing and the Personal Reconnection, are neither diagnosing nor treating specific health challenges. You are solely responsible for seeing to and continuing with your own medical treatment and care. Dr. Pearl endorses only those people whom he has specifically authorized to perform this work. Authorization may be verified through the office of The Reconnection, LLC –*

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