Celeste Buie, BSME, CMT, CCIe
Instructor, Facilitator
Client Forms


First-time Client Health History form
Screening Questionnaire form
Body Map for Clients
Physician's Permission form
Physician's Referral form

 

Raindrop and Emotional Release Testimonial Submission
Facilitator:  Celeste Buie, BSME, CMT, CCIe

Greetings,
You have the opportunity to create awareness through sharing your experience.  I am compiling testimonials on Raindrop (RD) and Emotional Release (ER) Techniques to further their study.  Rest assured that no personal information will be given to any outside entity unless you choose to volunteer it.  Your personal information is requested in case of further clarification.

I hope the findings of these submissions will offer the beginning of awareness of possibilities for mental health professionals, health care providers, therapists, insurance carriers, fellowships, support groups, and others to consider the application of  therapeutic grade essential oils with Raindrop and Emotional Release Techniques.  It is also hoped that this effort will be a catalyst for many studies yet to come. My thanks to you in advance for your cooperation. 

Sincerely,
Celeste Buie, BSME, CMT, CCIe

To submit, copy and paste the following into a document.  Fill out, sign and mail to address below.  Thank you for being willing to share your experience. 

Type of Session Received:  ___________________

Country:  ___________________________________

State or Province_____________________________

Gender_____________________________________

Age________________________________________

Please give a testimonial of what your session did for you.  Use space as needed.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

..........

Your Contact Information:

Name: __________________________________________

Address: ________________________________________

City: ___________________________________________

State: __________________________________________

Zip: ___________________________________________

Phone: _________________________________________

Alt Phone: ______________________________________

Email: __________________________________________

What is your occupation?

________________________________________________________

How did you learn about Raindrop and Emotional Release Sessions?

_________________________________________________________

If the information above is being provided by a parent or guardian, what is the name of the minor?

__________________________________

If possible, please include a testimonial from the minor, (along with the parent/guardian’s) in his/her own words, with as much detail as possible, of their sesion.

Do you have a medical or mental health practitioner's report, or other documentation that you could provide verifying benefits received from your session?  __________   

Would you be willing to sign a release form to share this information?  __________ 

Please check one:
Do not reveal my identity _____   
You may reveal my identity _____   

Your signature below verifies your permission to use the information you have provided in this survey.  Please print and sign your name and include the date below. 

Name Printed:  _______________________________

Signature:  __________________________________

Date:  _____________

Thank you for your participation.

Please return this form along with your testimonial to:

Celeste Buie, BSME, CMT, CCIe

26179 Novi Rd

Novi, MI 48375

Associated Bodywork & Massage Professionals
Member, Associated Bodywork & Massage Professionals 586.722.3593
26179 Novi Rd, Novi, MI 48375
© Copyright 2017 Celeste Buie, BSME, CMT, CCIe. All rights reserved.