New Client Intake Form

Full Name *

Email *

1. What made you reach out for this session right now? *

2. How would you describe your current health experience (physically, emotionally, mentally)? *

3. What are the main symptoms or challenges you’d like support with? *

4. What have you tried before? What helped, what didn’t? *

5. Are you currently working with any doctors or practitioners? *

6. Have you been diagnosed with a chronic illness? *

Yes

No

If Yes, Please Specify

7. Is there anything else you want me to know before we meet?

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