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New Client Form Part 1

Please complete this form as thoroughly as you can. Your answers will help me better understand your current concerns, goals, and overall wellness picture before we meet.

There are no perfect answers - simply provide as much information as you feel is relevant.

Contact & Preliminary Information

First & Last Name

Email Address

Phone Number

Age

What is your occupation/work schedule?

Please review the full Informed Consent Information before continuing:
Read the Informed Consent Information

My services are educational and wellness-oriented in nature and are not intended to replace medical diagnosis, treatment, or emergency care. Please consult an appropriate qualified healthcare professional regarding medical concerns, diagnoses, medications, or emergencies.

Your health and well-being are ultimately your responsibility. Meaningful change requires your active participation, willingness to recognize patterns, and consistent implementation of the recommendations, lifestyle adjustments, and self-care practices we discuss. I can provide education, support, and guidance, but I cannot make changes for you. If patterns are ignored and no action is taken, results are unlikely to change.

I confirm that I have read the Client Responsibility & Wellness Disclaimer above and reviewed the Informed Consent Information linked above, and I agree to proceed.