To follow is detail information to help you complete the Short Confidential Client Intake Form.

Primary Concerns

When writing your response please state your Symptom(s) AND Level see example below.
Level 1 (hardly notice symptoms) to Level 10 (symptoms are unbearable)

Example: Headache, level 3 / Or, NA (no symptoms at all)


Describe what you would like to accomplish with these treatments?

When writing your response please indicate Symptom(s)-Discussion (A) and/or Improvement Discussion (B).

Discussion (A):
ANY Symptoms that you may have experienced recently:

Headache Faintness // Dizziness // Tightness in Jaw // Weak body parts // Smoking (#/day__) // Nervousness // Poor Appetite // Excessive Urination // Grinding of Teeth // Heavy feeling in limbs // Blurriness of vision // Constipation // Loose Bowel Movements // Irritated Bowel // Pains in heart/chest // Indigestion // Insomnia // Fatigue // Cold in hands and feet // Lower Back pain – Shoulder/neck pain // Carpel tunnel syndrome // Menstrual Irregularities // Other: Are you pregnant?

Discussion (B):
ANY that you would like improvement in:

Negative self-talk, self-sabotage // Belief in the ability to achieve goals // Ability to relax // Ability to use dreams as a mental tool for problem-solving // Eliminate procrastination // Ability to reach ideal weight // Personal magnetism // Strengthen memory/concentration // Breaking old habits // Release negative events // Ability to align body/mind for self-healing // Ability to take action // Increase learning ability // Beneficial, relationships // Prosperity (attract what you choose) // Attitude and skills at work // Self-Esteem // Youthful Vitality

Disclaimer: These services are NOT a substitute for medical care or advice.