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<title>Healing Axis - Home</title>
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<h2>Healing Axis</h2>
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<li><a href="index.html">Home</a></li>
<li><a href="about.html">About</a></li>
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<a href="#">Services</a>
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<li><a href="areas.html">Areas of Focus</a></li>
<li><a href="practical.html">Practical Concerns</a></li>
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<li><a href="blog.html">Blog</a></li>
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<h4>Hello, how may we be of assistance to you? <br> To make an apointment, fill in the form below and send it back to us.</h4>
<form name="htmlform" method="post" action="html_form_send.php">
<table width="400" align="center">
<td width="268"></tr>
<tr>
<td valign="top">
<label for="first_name">First Name *</label>
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<td width="212" valign="top">
<input type="text" name="first_name" maxlength="50" size="30">
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<label for="last_name">Last Name </label>
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<input type="text" name="last_name" maxlength="50" size="30">
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<label for="email">Email Address </label>
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<input type="text" name="email" maxlength="80" size="30">
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<label for="telephone">Telephone Number</label>
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<input type="text" name="telephone" maxlength="30" size="30">
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<table width="405" border="0" align="center">
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<td> <input type="checkbox" name="friut" value="Addictions" />Addictions</td>
<td><input type="checkbox" name="friut" value="Emotions" /> Emotions </td>
</tr>
<tr>
<td> <input type="checkbox" name="friut" value="Phobias and Fears" /> Phobias and Fears </td>
<td> <input type="checkbox" name="friut" value="Eating Disorders" /> Eating Disorders </td>
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<td><input type="checkbox" name="friut" value="Relationships" /> Relationships</td>
<td> <input type="checkbox" name="friut" value="Sexual Concerns" /> Sexual Concerns </td>
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<div class="footer">Website designed by<a href="http://www.cjwebconsulting.com" target="_blank"> CJ Web Consulting</a></div>
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