- Please complete this form and click "Submit" at the bottom of the page. There's no need to print the form out, unless you'd like to keep a copy for yourself.
All client information is private and confidential.
Please write your name as it appears on your birth certificate (incl. middle names)
If yes, please indicate which condition.
ie. rashes, premenstrual pain, sleeplessness/insomnia, shortness of breath, migraines, constipation, dyspepsia, cystitis, incontinence, infections, coughs, colds, asthma, hypertension, diabetes, arthritis, cancer, heart disease, ulcers, etc...
e.g. car accidents, broken bones, falls, sprains, concussions, dental surgery, cesareans, etc.
i.e. pharmaceutical medicines (incl birth control), vitamins, supplements, herbal medication, homeopathics or flower essences, etc...
Diet & Lifestyle
Personal Health Concerns
I newsletters about 1-2 per month. No spamming, I promise!
Terms of Service
Before submitting your client intake form, please read the Terms of Service below.
All information collected in this form and discussed in your Kinesiology session will remain confidential at all times.
The healing process
Please be aware that recovering from a chronic, complex illness requires a commitment of time, energy, and resources. Progress can often be cyclical rather than linear. You may experience periods throughout your treatment where your improvement plateaus. This is normal. It is important to continue treatment through these cycles to achieve a successful outcome.
Other possible costs in addition to your session: Liquid Crystals and/or nutritional supplements
I'm also a Liquid Crystals practitioner, and will often prescribe a Liquid Crystals remedy to support your Kinesiology session. Remedies are either $7.50-$15 for a Single crystal or $21-$35 for a Trinity. Postage and handling (if required) is $10.
If your body tests up as needing nutritional supplement support, I do keep some stock on hand, and/or I can order supplements on your behalf. Supplement prices vary.
It's always your choice as to whether or not you'd like a recommended Liquid Crystals remedy or nutritional supplement.
I require 24 hours notice should you elect to cancel or reschedule an appointment. If you fail to attend a scheduled appointment without notice then the full cost of the session will be charged.
Repeated last-minute reschedules
If you find yourself in a pattern of rescheduling, even when providing 24 hours notice, this will also be considered a cancellation/no-show and the full cost of the session will be charged.
Agreement to Terms of Service
By filling out the required information, you agree that you have read and accept the above terms of service.