Client Intake Form

Please take a moment to provide some personal information and answer a few questions.



1.  Full Name

2.  Telephone Number

3.    Please check this box if I may leave a message at that phone number.

4.  Email Address (REQUIRED)

5.  Please describe your general health.

6.  Name of doctor, if currently under care

7.  Please describe any medication you are taking, and reason for taking it.

8.  Have you ever been hospitalized for an illness (physical or mental)? If so, please describe.

9.  Any recent major illness, surgery, or recurrent or chronic conditions?

10.  Do you smoke, drink, or take drugs? If drink, how much per day? If drugs, what kind?






© 2009 Jennifer Finlayson-Fife. All rights reserved.