Welcome to KarenGraceKassy.com

Offline Consultation Signup (If you are unable to print this page, contact our office via email. We'll send you a copy via regular mail)

-Please do not provide any other information besides name and age.
-Remember, consultations are not appropriate for emergency purposes.
-You can only fill out this form for yourself, not another person.

Dear Client,
Thank you for your inquiry. Below, please
 Sign & date. Fill out the form completely, or I cannot do the reading.
 Two forms of payment are accepted: check, money order or credit card
 Return this form to me with either a check made out to Karen Kassy for $165 (US FUNDS). (If you are a repeat client, send $145 US)
 OR pay by credit card:
Name on Credit Card: __________________________________
Visa/Mastercard number: _ _ _ _ -_ _ _ _ - _ _ _ _ - _ _ _ _ expiration: ___/___
Circle amount: charge my credit card $165 US (or $145 US if you are repeat client)

Signature: _____________________________
 As soon as I receive this, I’ll call you to set up an appointment. You must give at least 24 hours notice to change your appointment once it has been set.
 Please return to: Karen Kassy: PO Box 8043: Bend, OR 97708-8043
 NOTE: Do NOT send registered mail, certified mail, return signature required, etc., as this will only delay response time.
 DAYTIME phone number to reach you: _____________________________
 EVENING phone number to reach you: ______________________________
 EMAIL ADDRESS to reach you: ___________________________________
 I like to thank the people who send me clients. If you know who referred you, and how I can get in touch with them, I’d appreciate knowing:
_____________________________________

Disclaimer
I ____________________________________ __________ realize that the information
(Print your name) (and your age)
discussed with Rev. Karen Grace Kassy is spiritual in nature and is to be used for information purposes only. It should not and will not be used as a substitute for a physician’s or psychiatrist’s medical diagnosis, treatment and care. I realize any action I take is of my own, free will and I will assume all risks associated with the use of his information. I agree that I will not hold Karen Grace Kassy, in any case, liable, at any time, for any direct, indirect, special, incidental, consequential or punitive damages. I understand that there are no warranties made as to the information’s completeness, accuracy, currency or reliability as relates to this Life & Health Consultation and any discussion thereof.

I also realize that for legal purposes, I acknowledge that I do have a healthcare practitioner with whom I will consult if I decide to take action or change anything regarding my healthcare.
________________________________ ___________
Signature Date

OPTIONAL: your reading will focus on many things, and you are welcome to ask questions throughout. Some people prefer to let the process unfold. Others prefer to have prepared questions. If that is your preference, on the back of this form, write up to five (5) specific questions you would like addressed in the consultation (you can still ask questions throughout).. These could be 5 health questions; or 3 health, 1 career, 1 relationship, or any mix you prefer. The more SPECIFIC your question, the more specific the answer can be. This is optional.