Three Treasures Institute

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Information about applicant

Single Parent

Minor Child (under 18)

Senior Citizen (over 65)

Disabled

n/a

Number of Children in the Home

1

2

3

4

5+

n/a

Please select if you are one of the following populations:

Recent Immigrant (last 10 years)

Refugee

Prefer not to answer

I identify my ethnicity as (select all that apply)

Asian

Black / African

Caucasian / European

Hispanic / Latinx

Native American / First nations

Pacific Islander

Prefer not to answer

Other (please fill in the blank on the next question)

Our standard discount is 50% of the usual fee of our member practitioners. Is this a reasonable amount for you?

Yes

No

Do you have a preference of which practitioner you will be working with?

BESS DONLEY (www.bessdonley.com)

JASMINE ROSE OBERSTE (www.drjasmine.co)

NO PREFERENCE

Please check the appropriate box:

I am the patient/ applicant and I am 18 years or older

I'm the parent or legal guardian of the patient / applicant

Please complete the following section. PLEASE NOTE: ALL BOXES MUST BE CHECKED AND APPLICATION MUST BE SIGNED FOR THE APPLICATION TO BE PROCESSED:

The information presented in this application is true and complete to the best of my knowledge

I agree to and understand that while Three Treasures Institute is providing access to holistic and integrative healthcare consultation through discounted treatments, I will not hold Three Treasures Institute responsible for said consultation, nor will I take legal action under any circumstance.

I give Three Treasures Institute and its member practitioners permission to contact me using the contact information provided above