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CLIENT HEALTH INVENTORY + INTAKE FORM

Welcome — I’m so glad you’re here.

This form is part intake, part ritual — a sacred moment to attune to yourself and plant the first seeds of our work together. Your reflections will help me understand the landscape of your body, mind, and spirit so I can craft a protocol that is truly personal. Please share as fully as you feel called to. Everything you write will be held with care and kept in confidence.

About You

First Name

Last Name

Date, Time and Location of Birth

Phone Number

Email Address

Home Address

City | State | Zip

Sex assigned at birth

Emergency Contact

In the rare event of an emergency, is there someone you’d like me to contact on your behalf? This is entirely optional.

Name

Relationship

Email Address

Phone Number