INTAKE FORM

This form helps us to best help you, as well as provide a useful gauge for all involved on the effectiveness of the program and modalities offered. Thank you, and please let us know if you have any questions!

Part 1 : Basic Information
Name *
Name
Address
Address
Phone
Phone
Birth Date
Birth Date
Birth Time
Birth Time
Part 2 : Overall Health
If so, what are they?
If so, please describe.
Take a minute to scan your whole body with your awareness. Please check all the boxes for which you experience pain, tension, discomfort, or blockage. *
Rate your level of family stress *
Rate your level of work stress *
Rate your level of relationship stress *
Rate your level of financial stress *
Rate your level of health-related stress *
Overall, do you experience any of the following feelings to a degree to which you seek help or inquire about? Check all that apply.
Part 3: System Specificity
DIGESTION: Which, if any, do you experience, or have experienced in the recent past?
RESPIRATORY: Which, if any, do you experience, or have experienced?
CARDIOVASCULAR: Which, if any, do you experience or have experienced?
URINARY: Which, if any, do you experience or have experienced?
NERVOUS: Which, if any, do you experience or have experienced?
MUSCULAR: Which, if any, do you experience or have experienced?
OTHER: Which, if any, do you experience or have experienced?
FOR FEMALE IDENTIFYING:
FOR MALE INDENTIFYING: