New Client Intake Form

Please take time to read and complete the following:

  • Fill out the intake form below. Please fill out only what you are comfortable with. These questions are designed for me to become familiar with your health history, constitution, and any thing you are hoping to accomplish in our visit. For example, I will ask about food intake and digestion or stress levels because they are both vital parts of interconnected holistic health. Many patients find filling out this intake form is therapeutic for them and clarifies goals/history/etc. To reiterate, if there is any question you don’t want to answer, that is totally okay.
  • Please note any place you have a question and we will be sure to address it. We will go over this form together during the consultation.
  • Please bring all bottles of pharmaceutical and over-the-counter medicines, as well as supplements and tinctures that you take on a regular basis.
  • You are encouraged to bring along any medical records, blood tests, or other pertinent information you think may be helpful.
  • Client confidentiality will be observed under all circumstances.
  • If you discover that you are pregnant during the course of our work together, please discontinue all herbal supplements until we can discuss whether your recommendations need to be modified
  • If you have any questions, please contact me at

Please take as much space as you may need to answer any of these questions.

Thank you so much for filling out this intake form!