Client Intake Form

Your name

Your Address

Your Email

Your Contact Number

Referred By

Personal Information

Date of Birth

Place and Time of Birth

Religious/Spiritual Affiliation/Beliefs?

Marital Status

Number of Children

What days of the week and times of the day are ideal for your sessions?

Days of Week

Time:

Give one sentence that best describes your relationship with your parents

Mother

Father

List the techniques, processes or therapies you have participated in or experienced to date.

What is your current diet like? What percentage of your meals are home cooked?

Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?

What priority would you like to focus on for your session?

What would you like in your life 4-6 months from now?

Do you have physical challenges that would interfere with in-person muscle testing?
(e.g.: back/neck/arm pain or injuries)

At what point in your life did you feel best? Why?

What is one thing you LOVE about your life?

Are you currently taking any prescriptions or drugs?

I understand and agree that I am individually responsible for my own life and it’s unfolding.

As an expression of my responsibility I am seeking assistance with the beliefs that
manifest my reality, but the actual manifestation of that reality is up to me. I’m committed to my session(s).

I also understand that cancellations or rescheduling of appointments requested less than 24 hours prior to my session time result in a forfeit of that session.

I Accept the above terms

Δ