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Intake Form

Please fill out the following form
in order to participate in our activity.


Please describe the areas of your health that you would like to see improvement in, from most troublesome to least. (Please include dates when each issue occurred.)

Past medical history (previous injuries, accidents, surgeries, etc.) Please describe and include approximate dates.

List the medications, vitamins, supplements (including over the counter, herbal or homeopathic) you are presently taking:

Have you taken antibiotics in the past? If so, when?

Do you regularly consume:  alcohol, nicotine, recreational drugs? If so, which and how much, how often?

Please indicate your CURRENT stress levels in each area below.









What areas of your life give you joy and energy?

Do you exercise? And if so, what kind and how often?

Do you do other activities regularly (gardening, dancing, etc)? How many hours per week?

How many hours a night do you sleep?

Is your sleep restful? If not, please explain:

Have you had any past experiences that still affect you deeply (trauma, accident, grief, vaccine, illness, etc.)?

Are there any specific areas of pain or discomfort you experience? What is the area of pain? Rate the pain from 1 to 10 (1 is Lowest, 10 is Highest):

Do any family members have similar health issues? If so, please describe:

What would a successful MInd-Body Session outcome look like for you?

Please let us know... are you available for follow-up communication with your practitioner?

How did you hear about us?


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