Light Therapy Resource Initial Consult Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.Preferred Email Contact Method
example@example.com
3
What can we help you with today?* This field is required.
Chronic (Long Term) Issue
Acute (Recent) Issue
General Questions
Need Help Selecting a Device
Other
4
Please explain the reason for your consultation request in greater detail below. The more detail we have, the easier it will be for us to respond and schedule your consult.
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5
How much experience do you have with light therapy?* This field is required.
I know nothing about it
I have heard about it, but not tried it
I have tried it once or twice
I own a device
I am totally obsessed and own multiple devices
6
Are you interested in potentially meeting with a Certified Light Therapist in person in your area for a light therapy session and customized treatment program?* This field is required.
Yes
No
Maybe, not sure
7
If we are able to assist further, our fee will be $100 for a 30 minute Zoom session or $175 for a 60 minute session (other options available upon request) and this will include a digital copy of our most popular Photopuncture Chart (using light instead of needles to activate acupoints on the body) which will give you an example of what our charts look like and how you can use them for Target Light Therapy. If you would like any customized Photopuncture Charts created, the cost will be $100 per chart. For more complex issues, we can discuss on a case by case basis. Does the above sound good?
YESNO
8
Our consultations are typically conducted over Zoom. Will this work for you or do you require any accommodations?* This field is required.
Yes
No, I require accommodations
9
If you would prefer a different method of communication, please explain in more detail below how we may accommodate you.
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