New Client Intake Form

Thank you for requesting an appointment. We will be in touch soon so that a specific date and time can be scheduled.

In the meantime, if you would like to get a head start on the New Client Intake Form, you can fill it out below and the information will be forwarded to us privately and electronically. Or, you may download it as a PDF here and bring the hard copies with you to the appointment.

Intake Form

Step 1 of 3

Date*
MM slash DD slash YYYY
Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Home Phone*
Cell Phone*
Preferred Phone*
Date of Birth*
MM slash DD slash YYYY
Your Age*
Referred By*
If no one referred you, please reply N/A.
Emergency Contact Relationship*
Emergency Contact Phone*
Occupation/ Daily Activity*
Living Situation*
Family, pets, friends, etc.

Health History
Health Care Professionals You See*
Physician, Nurse, PT, Counselor, etc.
Experience with Energy Medicine or Other Related Modality*
Acupuncture, massage, etc.
Health & Medical History*
Please list any illnesses/ health issues/ surgeries (include date of surgeries)
Accidents*
Medications*
Allergies*
History of Addictions*
Diet/ Nutrition*
Sleep/ Hours per night/ any challenges?*
Exercise (What kind? Frequency?)*
Stress Reduction/ Relaxation Techniques*
Spiritual Practices*

Current State of Wellness
Reason for Scheduling Healing Touch Session*
Any Difficulties Focusing or Concentrating?*
Pain*
Please rate your pain on a scale of 0 to 10; 0 = no pain, 10 = very painful.
Please describe your pain.*
Where is it located? Is it throbbing, aching, sharp, continuous or intermittent?
Stress*
Please rate your stress level on a scale of 0 to 10; 0 = no pain, 10 = very painful.
Please describe your stress level.*
Do you have personal stress? Work stress? Other stress? What is it caused by?
Please rate your current state in terms of the following areas of wellness.*
0 = low level of wellness 10 = high level of wellness
Physical (Energy Level)*
Emotional (Happiness and joy)*
Mental (Positive outlook and self-talk)*
Spiritual (Connection to something greater than yourself)*
Goals for Healing
Goals for Healing: Short Term*
Goals for Healing: Long Term*
Is there anything else you would like me to know about you before we meet?*

New Client Intake Form

Intake Form

Step 1 of 3

Personal Information

Health History

Current State of Wellness

Goals for Healing