Client Session Intake Form

Name

First Name

Last Name

Phone

Country

(###)

###

####

Preferred Method Of Contact

Primary Goals For Our Session:

Are You Currently Under Medical Care? If yes, please expand to the extent you feel comfortable.

On a scale of 1-10, how ready and willing are you to make significant lifestyle changes?

Please complete the "Holistic Health Simplified: Self-Assessment Questionnaire" (linked below). Based on these results, share your top 3 insights or possible areas of priority.

Any other information you would like me to know prior to our session?

Would you like to receive an optional biofeedback scan as well as harmonizing frequencies during your session?

Yes

Holistic Health Simplified: Self-Assessment Questionnaire