New Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How old are you? * Occupation * Medications * Briefly describe any chronic medical conditions and physical pains that are concerns for you * What ONE main issue would you like to work on in your package? * If I had a magic wand, what would you want me to fix? * How was your relationship with your parents growing up? How is it now? * How was your relationship with your siblings growing up? How is it now? * What is your relationship status? Anything I should know about your relationship history? * If you have a partner, how is your relationship with them? * Do you have any children? What is your relationship like with them? * Have you experienced any kind of trauma? * Have you worked with a life coach, therapist, or healer in the past? How was your experience? * Who do you go to for emotional support? * Is there anything else you would like me to know that will help with our work together? * Who referred you to work with me? * Thank you!