Intake Form

Client Intake

  • Current Health Status:

    In order to keep you safe and meet you where you are right now, it is important to know if you have had any of the health issues listed above.
    Health challenges and illness sometimes manifest shortly after a major personal stress such as a change in work or money status, moving, marriage, death, illness of a loved one, childbirth, miscarriage, separation or divorce. Has such an event occurred for you in any of the time frames above?
    Check all that apply.
    Check all that apply
  • Specific Needs and Hopes for Our Work Together

    Indicate all that apply
  • Thank You for Letting Me Know About You, And Your Hopes and Expectations

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