Intake form
Please fill out all of the following information before our session together. Questions? Email me at sol19@ymail.com
Email address *
Your full name: *
Your answer
Address: Street *
Your answer
Address: City *
Your answer
Address: State *
Your answer
Address: Zip code *
Your answer
date of birth *
MM
/
DD
/
YYYY
Astrology Chart information: Place of Birth *
Your answer
Astrology Chart information: Birth time . (exact time) *
Your answer
Your cell phone number: *
Your answer
Your home phone number:
Your answer
What is your Skype ID?
If we will be doing virtual sessions together. Don’t know it? Here’s how to find it: https://support.skype.com/en/faq/FA10858/what-s-my-skype-name
Your answer
Your occupation: *
Your answer
Your emergency contact name: *
Your answer
Your relationship status? *
Your answer
Number of Children and ages *
Your answer
Your emergency contact phone number: *
Your answer
Are you presently taking any medications, herbs, supplements? *
If yes, please list name and reason for medications, herbs, supplements:
Your answer
Do you smoke or self-medicate with any substance(s)? *
If yes, please explain type and use *
Your answer
Have you had a recent major surgical procedure, hospitalization or injury? *
If yes, please explain
Your answer
Have you ever received ... *
(Check all that apply)
Required
Are you currently seeing a Chiropractor, Physical Therapist, Physician, Psychiatrist, or other Alternative Practitioner for an ongoing issue? *
If yes, what is the issue and what sort of practitioner are you using?
Your answer
Are you allergic to any lotions or oils? *
Any other known food/drug allergies? *
Your answer
Do you have any of the following today?
What are your intentions for this session? *
Your answer
What brings you ease, joy, inspiration, or sense of belonging in your life? *
Your answer
Do you have animal friends in your life? *
Do you have a reflective or mind/body practice? *
What do you do for exercise? *
Your answer
What is your stress level? *
Low
High
Are you currently under an emotionally intense period or transition in your life? How are you supporting yourself or managing during this time? List some of your resources. *
Your answer
Have there been any big changes or losses recently in your life? (Living situation, work, family, relationships) *
Your answer
If you know about your birth process, please share any information you can; complications, trauma, medical interventions as well as what was happening in your family emotionally or psychologically. *
Your answer
Is there anything else you would like me to be aware of so that I can support you more fully? *
Your answer
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