Nova Guidance Journey Intake

NOVA GUIDANCE Intake

amplified consciousness and the natural world
Thank you for your interest.

The information you provide here is for the creation of a safe container for working together. Please provide honest and comprehensive answers. Everything will be kept confidential.

During our intake session, we will discuss your responses here, including your experience with expanded states of consciousness and emotional and spiritual aspects of your present wellbeing.

While I am trained to screen for medical contraindications, I am not a medical doctor. However, I have access to medical professionals for the purpose of safe and comprehensive screening should any element reside outside of my scope. As necessary, I will provide a referral for medical and pharmaceutical advice.

It is an honor to support you.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birthdate

MonthDayYear
Date
Emergency Contact (name, #, relationship)
Please list any current medical conditions or mental health diagnoses that are presently under professional supervision or treatment:
Please list any current prescription medications, OTCS, or supplements including dosage and frequency, purpose, and how long you have been taking them:
Please list any known allergies (include food and medications):
Have you ever received any type of mental health diagnosis or treatment in the past? (Please include medications, support received, and pertinent dates):
Do you have a family history of mental health disorder?
Do you have a personal or family history of any cardiovascular condition?
Are you currently engaged in work with any type of counselor, mentor, spiritual guide, or support group?
Should be Empty:

NOVA GUIDANCE Intake