Client Intake Form
Deborah Lee, Holistic Health Practitioner PhD
Four Winds Farm
3729 N 36th Quincy IL 62305
217-257-1480
All information is strictly confidential
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Name *
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Cell Phone number
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Please state your main reason for seeing Dr. Lee, and any outcomes you would like to accomplish from this therapy.
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Date and place of birth:
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Brief description of living situation including marital status
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Employment/and or daily household responsibilities
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Please describe your general lifestyle including hobbies, artistic interests and creative expressions:
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Please provide a brief description of your basic state of health, including key medical history,diet, exercise, physical weight, energy level, etc.
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Are you currently engaged in other therapies or significant healing programs? Are you taking any pharmaceutical medications? Are you following a specific diet or any related health measure?
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How do your feel about your work and other vocational interests?
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Are you involved with community or other volunteer activities?
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Briefly discuss your family of origin and any significant childhood events or challenges:
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Please comment on your relationships with members of your childhood family; both past and present, also current relationships.
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What aspects of your life have been the most challenging to date? How have they provided recurrent themes for learning and development?
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