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The First Visit — Confidential Questionnaire

This intake form allows us to gather the essential information needed to personalize your session and ensure you receive the most effective and tailored care. Completing this form helps us prepare your treatment and support you in the best possible way.

Practitioner's Choice

For your First Visit, which practitioner would you like to work with — Mathieu or Lucie?

For your First Visit, which practitioner would you like to work with — Mathieu or Lucie?

Understanding You

What made you decide to book now ?

How long has this been going on ? What have you already tried that didn't fully help ?

Is there anything you're worried we might do during the session ?

Basic Information

Last Name

First Name

What is your phone number ?

What is your email adress ?

In which language would you prefer to communicate?

Your Current Experience

What is the main problem or concern that brings you here today ?

Do you have other problems or concerns you would like to adress ?

General Context

How would you rate your energy level on a scale of 1 to 10 ?

How would you rate your energy level on a scale of 1 to 10 ?

How are you sleeping at the moment ?

How would you describe your overall stress level ?

How would you describe your overall stress level ?

Are you currently taking any dietary supplements or medication?

If yes, please make a quick list below.

If no, please enter 0.

Have you ever had any significant injuries and/or surgeries ?

If yes, please list them below.

If no, please enter 0.

Your Intention

Tell us what you would like to get out of this first visit ?