Intake Form

Your Information and Areas of Focus:

Thank you for reading the following information and sending me this intake form. In order to fully take advantage of our time together, I ask that you send me some basic personal information and brief descriptions of your areas of focus. These areas can be emotional, physical, relationships issues or anything that holds your conscious attention.

Privacy Policy and Informed Consent:

Before filling out this intake form, please read the privacy policy and the informed consent information. Please check the box at the bottom of the intake form that you have read this information.