Intake Form

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Intake Form

This form will help me prepare to meet you. The information you provide will remain confidential.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Preferred Phone Number *

Pronouns *

Date of Birth *

Gender at birth *

Emergency contact - name, phone, relationship *

Symptoms and Goals

What areas, concerns, or goals would you most like help with now?

Please describe below *

Medical History

Please list the main other healthcare practitioners you are seeing:

Practitioner 1 *

Practitioner 2 *

Practitioner 3 *

Practitioner 4 *

Please list any surgeries, major illnesses and other traumatic or life-threatening experiences (and indicate the year or your age)

Comment *

Women only - Are you pregnant? *

Yes No Uncertain

Lifestyle

Do you have any dependents in the house? *

What is your relationship status? *

On a scale of 1-10 what is your overall stress? *

Do you have an exercise routine? Please describe: *

Do you do anything for relaxation? Please describe: *

How many hours per night do you sleep on average? *

Do you wake rested? *

Yes No

How much and how often do you consume the following:

Alcohol *

Caffeine *

Tobacco *

Other psychoactive substances (pharmaceuticals or plant medicine) *

Briefly describe your dietary habits (e.g. Number of meals per day, type of food enjoyed): *

Bowel Movements *

Hard Soft Normal Infrequent Regular Frequent

Family History

Were you adopted? *

Yes No

If Yes, do you have a relationship with your birth parents? *

Did you grow up in a home with both of your parents (birth or adoptive)? If no, please elaborate. *

Do you have any siblings? If yes, please state how many, and your position in the family (e.g. eldest daughter, 2nd youngest son, etc) *

How would you describe the emotional climate of your home growing up? *

What 2-3 words would you use to describe your mother? *

What 2-3 words would you use to describe your father? *

Did you have a relationship with maternal and/or paternal grandparents? *

What is the country of origin of mother? *

What is the country of origin of father? *

Are you aware of any major traumas that your parents or any of your immediate ancestry (grandparents, great-grandparents, aunts or uncles) experienced?

Please describe very briefly. *

On a scale of 1-10, how much belonging do you feel now in your family of origin? (even if your parents have passed on and you don’t have any siblings, how much do you feel your place in the lineage)

1 (low) to 10 (high) *

Energy and Emotional Health

Untitled On a scale of 1 (low) to 10 (high), please rate your overall energy level: *

What time(s) of the day are your energy levels at their highest? *

What time(s) of the day are your energy levels at their lowest? *

On a scale of 1 (low) to 10 (high), please rate how happy you are generally: *

How do you feel emotionally? *

How would you describe the emotional climate of your home? *

Any other comments regarding your energy levels and/or emotional and mental health? *

Is there anything else you would like to include on this form? *

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About
Offerings
Contact
Book Now