Client Intake Form

Name

Email Address

Phone Number

What is the best way to reach you? Phone or email?

What are your top 3 health and wellness goals?

What are you looking to gain by working with me?

What have you tried in the past that has worked? (such as diets, therapies, remedies or working with health practitioners)

What have you tried that didn’t work?

On a scale of 1-10, how committed are you to making changes to support your overall health?