A Holistic Approach
to Wellness

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For more information or to begin the healing process, please fill out the questionnaire provided.

That will help me determine how best to serve you. I will email you to arrange appointments and discuss fees.

No solicitations please.

Nessa Lear RN BSN MA FAAIM
The Fifth Gate
Email: Nessa@theFifthGate.com

* =Required Information - Please answer the questions listed below so that I might better understand how to help you.

*Name
* Preferred Phone -  -    Ext. 
* E-Mail Address
* Confirm E-Mail
Street Address
Address Line 2
City
State
Zip
Date of Birth
What do you do for fun?
What do you do for work?
Have you ever worked with a healer? Yes     No
If so, what modalities have you tried?
How did it help you?
Is there anything in your current or past medical history, including physical, emotional or psychological conditions that I should know of in advance?
What would you like me to help you with?
  I give The Fifth Gate permission to send emails.
Hold Harmless Clause: By clicking “submit” below you signify your acceptance of this statement.

I, the undersigned am over the age of 18 and understand that I am requesting support from The Fifth Gate for physical, emotional, or psychological conditions that already exist. To the best of my knowledge, I do not have any conditions that would preclude me from receiving healing. I understand that healing and consultations are an adjunct to medical or psychological care and are not a replacement. I therefore agree to accept all risk and responsibility for any injuries or damages suffered by me while using The Fifth Gate services. I have read these statements and agree to hold The Fifth Gate harmless.

     

Working with each client – the healer stimulates a dynamic unending process that supports your natural evolution towards greater vitality and integration of body-mind-spirit.

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