Intake Form

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Is there a certain time of day or night that is a struggle (i.e. If you wake up at night, what time)?

Please list your marital status

Please list any mental health/medical/surgical/injury history (current or past) you would like to share

Please list any allergy or sensitivity (history or current)

Please list any medications, vitamins, or supplements you are currently taking that you would like to share

Do you consume alcohol, caffeine, tobacco products, vaping, or drugs (if so, what and how often):

Top 3 areas of concern in your life:

What would it mean for your life if these issues were gone tomorrow?

Do you believe healing is possible for you?

Anything else you would like me to know (more details the better, but no pressure to share)

Please share a photo of you (or the client)

Initials

I declare that the info I’ve provided is accurate and complete.

I consent to allow this practitioner to have access to this personal health information I have listed in this secure location.