This Form is designed to be completed prior to our first session, we may have already spoken and I referred you to this form.

I am so happy you've made to this far on your journey! I'm really looking forward to meeting you and assisting you in improving the quality of your life! In order to make the quickest progress and not spend the first session asking you these questions, I've prepared a form that will give us a head start in developing an understanding of your current state. This is just a starting point and we can review and change any of your responses, please don't let this frustrate you in any way. We can answer any of these questions in our first session if you would prefer to answer these in person. Once you complete the form just hit the "Submit Form" button at the bottom I'll be in touch within 48 hours.

If referred, by whom?

Required Information

Client Name (required)

Your Email (required)

Phone Number (required)

What would you like me to help you accomplish?

Health History:

Note: Many psychological challenges manifest physical symptoms. Listing the symptoms past and present will greatly help in understanding mind health and past sensitizing events clearer.

What is your age?

Please list all illness diagnoses, treatments, and surgeries.

Do you have any chronic issues? For how long and when did you first notice them?

Do you have any stomach/intestinal issues? For how long and when did you first notice them? What causes flare ups?

Do you have any skin rashes or discolorations? For how long and when did you first notice them? What causes flare ups?

Do you have any other unusual or strange symptoms? For how long and when did you first notice them? What causes flare ups?

Please list all medications you are taking, for what, and how long you have been taking each medication.

Do you use tobacco/niccotine products ? How much per day? If not click "I don"t use tobacco products"

I don't use tobacco

How often do you drink alcohol products? How much per day/week? If never click "I don"t drink alcohol"

I don't use alcohol

What type of physical activity do you do weekly? How much per week?

Nutrition:

Please quickly describe everything you eat and drink on a typical day

How often do you eat leafy green plants per week?

How much water do you drink daily? What other drinks do you consume regularly? How much and how often?

Sleep Quality:

Please describe the quality of your sleep. How much do you sleep per night? Do you have any issues sleeping?

Additional Comments - Please submit form using "Send Form" button below.

Occupation info:

What is your occupational background, training, or current job?

Do you currently have any occupational issues or problems that you would like help with?

What do you find fulfilling about your current job/occupation?

Relationship information:

Please give a brief overview of your immediate family (Married/partnered (how long), number of kids (with ages)):

Are you seeking help with any relationship? Please elaborate:

How would your friends describe you? How would you describe yourself?

Session Goals:

Please describe what you would like to achieve with my help? What be the best case scenario outcome from our work together? How will working together improve the quality of your life? What are you looking to accomplish? What are your dreams, goals or aspirations?

What is the more important thing to know about you? What piece of information is critical to solving your puzzle? What is holding you back from accomplishing your dreams? What is the biggest challenge or obstacle in your life right now?

What is the more important thing to know about you? How would your friends describe you?