Human Intake Form I look forward to working with you and will be in touch shortly! Your Name * First Name Last Name Email * Phone Number * (###) ### #### Location and Timezone * What is your preferred contact method? * Check all that apply Phone Email Text What is your preferred method of payment? * Check all that apply Zelle Venmo Paypal Credit Card Check How did you find me? What is your main concern? What brings you to me today? * How long have these issues been going on? * ◇ HEALTH HISTORY ◇ Gender Age List any supplements you are taking: List any medications you are taking: Include length of time you have been on them. Any known previous trauma? Including birth, childhood, relationships Known allergies: Any issues with sleep or digestion? Be specific. Current or past diseases/illnesses/infections: Previous or current injuries: Describe any emotional or mental health issues: List any other members of the family: Both animal and human Past surgeries: What are you doing or what have you previously done to address any physical or mental health issues? Do you have a medical diagnosis? Is there anything else you’d like to add? Thank you! Your intake form has been sent.
