Initial session form

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Do you feel your visit will address:

Physical body

Emotions

Mental well-being

Spirit/Soul

Do you have a restful sleep every night?

Yes

No

Do you exercise regularly?

Yes

No

Sometimes

Are you currently taking any dietary supplements or prescribed medications?

Yes

No

Close your eyes and take a moment to notice how you feel. Write and/or check all that apply to describe how you are feeling. *

Joyful

Afraid

Stressed

Restless

Judged

Happy

Sad

Irritable

Depressed

Angry

Worried

Lonely

Anxious

Peaceful

Uneasy

Grieving

Overwhelmed

Impatient

Other