confidential questionnaire

Client Intake Form

All information is held with the strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel infringes on personal information or that you do not wish to disclose, or any irrelevant question. Please consult the Privacy policy on my website for more.

Thank you for contacting me.

Toute information soumise est strictement confidentielle. Aucun data ou information ne sera jamais divulgué à aucun autre parti sans consentement écrit de votre part; Vous pouvez choisir d'ignorer certaines questions ci-dessous si elles ne vous concernent pas ou vous les considérez trop personnelles. Veuillez consulter la Police de confidentialité sur mon site.

Merci de votre intérêt.

Mylène @ Evolutionary Healing

Full Name*

First NameMiddle NameLast Name

Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Phone Number*

E-mail*

example@example.com

Occupation

Medications

Allergies

1.How can I help you?*

2. How long have you been experiencing the above?*

3.What symptoms are you experiencing?*

4. Please list and describe any other condition that you think I should know about*

5. Have you ever been in an accident (automobile, work, falls, etc.) ?*

6. If so please list all related treatments received for this injury.

7. List history of surgery or other traumatic events + approximate year*

8. How would you describe your life at the moment?*

9. Would you describe yourself as emotional? What emotions or feelings do you struggle with most?*

Do you think of yourself as 'Spiritual' and how so?*

What would you like to change in your life and what would you gain from that change?*

10. Have you ever experienced depression/anxiety/panic attacks or mental imbalance?*

11. Please list exercise and stress reduction activities (including frequency).*

12. Are you currently seeing any other healthcare professional?

Is there anything else you think I should know?

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Can I add your email to my mailing list? You will only receive occasional information about Evolutionary Healing Circles/sessions and occasional events.*

Yes pleaseNo thank you