Client Intake Form
Please complete this intake form prior to your appointment. Your responses help us provide the best possible care.
Cancellation Policy Agreement
*
I agree to the cancellation policy
Cancellation Policy Agreement - Name
*
Informed Consent Agreement
*
I agree to the informed consent statement
Informed Consent Agreement - Name
*
Name
*
Age
Phone # (Home)
Please enter a valid phone number.
Format: (000) 000-0000.
Phone # (Cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Preference
Please Select
Home
Cell
Full mailing address
E-mail Address
example@example.com
Referred by
Date of Appointment
-
Month
-
Day
Year
Date
Day of Week
Time
Current health goal / what do you hope to get out of this session?
Issue 1 - Description
Issue 1 - Severity (1-10)
Issue 2 - Description
Issue 2 - Severity (1-10)
Issue 3 - Description
Issue 3 - Severity (1-10)
Issue 4 - Description
Issue 4 - Severity (1-10)
What do you believe is/are the cause(s) of these issues?
What have you done thus far to help alleviate these issues?
Are you currently under the care of a physician? If so, what for?
Most pressing current physical and emotional health issues
Past accidents?
Operations?
Specific spiritual practice
Anything else you think I should know?
Do you have allergies?
Please Select
No
Yes
Allergies - to what?
Medication or herb allergies?
Please Select
No
Yes
Medication or herb allergies - to what?
Food allergies?
Please Select
No
Yes
Food allergies - to what?
Sensitive Skin?
Please Select
No
Yes
Sensitive Skin - to what?
Anxiety and feeling overwhelmed or stressed, especially anxiety felt in the body, or physical anxiety
Check if applies
Feeling worried or fearful
Check if applies
Have intrusive thoughts, have an overactive brain, or have unwanted thoughts – especially thoughts about unpleasant memories, images or worries
Check if applies
Panic attacks
Check if applies
Unable to relax or loosen up
Check if applies
Stiff or tense muscles
Check if applies
Feeling stressed and burned-out
Check if applies
Obsessive thoughts or behaviors
Check if applies
Perfectionism or being overly controlling
Check if applies
Irritability
Check if applies
Winter blues or seasonal affective disorder
Check if applies
Negativity or depression
Check if applies
Excessive self-criticism
Check if applies
Craving carbs, alcohol, or drugs for relaxation and calming
Check if applies
Low self-esteem and poor self-confidence
Check if applies
PMS or menopausal mood swings
Check if applies
Hyperactivity
Check if applies
Anger or rage, agitated easily or irritated
Check if applies
Digestive issues
Check if applies
Fibromyalgia, temporomandibular joint syndrome, or other pain syndromes
Check if applies
Difficulty getting to sleep
Check if applies
Insomnia or disturbed sleep
Check if applies
Lack of energy
Check if applies
Lack of focus
Check if applies
Lack of drive and low motivation
Check if applies
Attention deficit disorder
Check if applies
Heightened sensitivity to emotional pain
Check if applies
Heightened sensitivity to physical pain
Check if applies
Crying or tearing up easily
Check if applies
Eating to soothe your mood, or comfort eating
Check if applies
Submit Intake Form
Should be Empty: