Long Intake Form

Althea Gray, Human Potential Healer

Our Purpose is You

Long Intake Form

*Month-Day-Year
*Month-Day-Year, Time & Place if known
*Please leave the best number without any spaces or symbols in between numbers.
Describe the Alternative/Integrative Therapies if you select "Yes"
Draw on a piece of paper and email to althea@altheagray.com
*Month-Day-Year
Althea Gray
Santa Fe, New Mexico 87505
Phone: (505) 983-9582
Email: althea@altheagray.com

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