Client Intake Form Fill out the form below and submit online or click here to download/print as a PDF and submit via snail mail. If you choose to mail your documents, please be sure to include Intake Form, Consent Form with photo to: PO Box 501, Fairfield CT 06824. Name*DOB Date Format: MM slash DD slash YYYY Today's Date Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* GenderWeightHeightOccupationReferred ByEmergency ContactRelationshipTelephoneDescribe Current Conditions/SymptomsDescribe how your problem(s) started. What was happening in your life before symptoms manifested?Describe a typical day in your life – how and where you spend your time and with whom you spend it. How do you generally feel about your day to day routine? Please elaborate on any aspect that comes up for you that feels right to shareWhat is your goal and intention in pursuing this method of healing?Health HistoryChildhood Diseases Measles Mumps Rubella Chicken Pox Pneumonia Whooping Cough Scarlet Fever Other OtherVaccinations MMR DPT POLIO CHICKEN POX TB Rotavirus HIB Hepatitis HPV Flu Menningococcal Pneumococcal Other OtherPlease list previous injuries and/or surgeriesPlease list current medications and purposePlease list any diagnoses and/or diseasesPlease list habits that concern youDescribe your exercise or fitness routineDescribe your sleep patternDescribe your digestion and any special diets or restrictionsAllergies, Sensitivities or Intolerances? Such as to foods, sound, touch, etc..Major Health Problems of blood relatives on maternal and paternal sides (mother, father, grandparents, aunts, uncles and siblings)If you are writing for your child, please share what you can about your pregnancy experience – what your stressors were, medications taken, what was going well and what you felt wasn’t going well. Also share what you can about your labor and delivery experience.Additional CommentsINFORMED CONSENT AND LIABILITY RELEASE* I agree to the terms outline here.