I. Patient Information

Full Name *

II. Contact Details

Mailing Address Zip Code Preferred Contact Method

III. Emergency Contact

Full Name

IV. Referral Information

How did you hear about us?

V. Health Information

Are you currently under the care of a physician or mental health professional? Are you taking any medications or supplements? Have you had any recent surgeries, diagnoses, or major health concerns? Are you currently pregnant? Do you have a history of (check all that apply):

VI. Wellness Goals & Intentions

What brings you in today? (Optional) Primary goals for our sessions (check all that apply):

VII. Consent & Acknowledgement

I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.

I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.