Short Confidential Client Intake Form

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.