Client Intake Form

If yes, please specify? If no, indicate NA
Indicate reason for medication?
Please specify? If no, indicate NA
Please specify? If no, indicate NA
Indicate NA if not applicable
Indicate NA if not applicable.
I further agree that the therapist/coach assumes no responsibility for the outcome of the process and for guaranteeing its efficacy. Alternative healing is not intended as am medical diagnosis and is not intended to replace any medical advice. Alternative healing, coaching and therapy is for the purpose of improvement of wellbeing. I will inform therapist if I have any medical conditions, or anything else that might affect a therapy during the therapeutic process. I understand that this also consent that sessions will include video recording for the therapist to review session at a later time. All sessions are kept strictly private and confidential by all parties and shall not be reported except for certain mandatory reporting required.
[Electronic Signature Agreement] By keying in my name, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement and I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. With this Electronic signature I consent to be legally bound by the terms and conditions listed below.