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Name

Phone

City, Province, Country:

What is/are your primary health concern(s)?

How long has this concern(s) existed?

Have you previously sought other forms of medical support or therapy for this concern? If so, what?

What emotions are you experiencing currently and/or recently, related to this health concern(s)?

Do you have a loving, supportive circle of friends and/or family?

Do you have anyone willing to support you - at least check in with you intermittently - as you walk through this healing journey?

Do you have any other concerns, questions, or comments you would like to share?

More in-depth questions will follow shortly, in the intake forms.