Intake Form

Integrative Healing & Wellness

All information provided herein is confidential. We respect your privacy.

Name

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Consent to Evaluation & Treatment

I understand that I have the right to question and/or refuse any aspect of evaluation, treatment and/or recommendations offered to me at any time. I understand my autonomy and comfort are paramount and I give my consent for evaluation and treatment with this understanding. I will consult my personal physician should I have any medical questions or concerns.

Sign Name Below

Please type your name here to represent your signature and informed consent

Occupation/Activities that comprise your typical day?

Please describe below

Leisure Activities/What do you do for fun?

Please describe below

Please list ongoing medical conditions and known allergies

Please list all medications/supplements

What is your goal/intention for our time working together?