Client Intake Form

Please complete this form to the best of your ability. After you submit the form - don't forget to contact me to schedule your appointment. Thank you.

Name(Required)

First Last

Referred by:

Date of first appointment (if available):

Your Contact Information

Email(Required)

Home Phone(Required)

Cell Phone

Address(Required)

Street Address City State ZIP Code

Share some basic information about yourself and your concerns.

Your answers are private and confidential. Some questions are required and marked with an asterisk.

Home Life(Required)

Date of Birth:

If children, list their ages:

List ages separated by a comma.

If pets, type/ages:

Please list type and age, separated by commas.

Occupation:

General health status:

Please state general, current health status.

Primary reason for visit:(Required)

What do you believe is the reason for your current health concerns (if any)?

Have you had any experience with Healing Touch or other energy medicine modalities?

Thank you!

I look forward to meeting you. Please contact me at (847) 736-5911 to schedule your appointment. Additional intake information will be requested during your first visit to assess your needs and concerns.

Please check the box below:

Your Contact Information

Share some basic information about yourself and your concerns.

Thank you!

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