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New Client Intake Page 1 of 6
List the health concerns that you’d like us to address in order of importance
How long have you suffered fromeach of these health concerns?
If not addressed previously, do you desire to improve any of the following? Check all that apply.
New Client Intake Page 2 of 6
List the therapies, and/or approaches you’vepreviously used to resolve each of your health concerns:
When your symptoms are at their worst, how do you feel?
Which parts of your life do these health concerns interfere with or impact?
Explain how your health concerns interfere with the above checked areas:
New Client Intake Page 3 of 6
What effect do they have on your bodily functions (headaches, digestion, joints, etc.)?
How have you managed your health concerns previously? Check all that apply:
How have the above methods worked for you?
If your health concerns were resolved, how would your life improve? Check all that apply:
New Client Intake Page 4 of 6
How have your health concerns impacted your home life and/or relationships?
On a scale of 1 to 10 (1 = Not motivated, 10 = Highly motivated), howreadyare you to make the lifestyle changes that may be needed for you to reach your goals?
List the strengths that will help you achieve your goals:
The information completed above is true and answered to the best of my ability.
I understand that I am responsible for payment of all services provided to the client.
If you checked “No”, please list financially responsible person:
User Name :
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New Client Intake Page 6 of 6