Short Intake Form

Health is a journey, not a destination. My focus is on restoring health, not just treating disease, to improve your quality of life and prevent chronic illness. I work with those ready for change and will refer you elsewhere if I’m not the right fit.

Fill out this quick 5-minute application to see if we’re a good fit. If I can help, we’ll move forward. If not, I’ll provide guidance on next steps. I look forward to connecting with you!

Full Name

Date of Birth

Sex

Address

Phone Number

Email Address

Have you worked with a holistic practitioner before?

What are your wellness goals?

Why are you interested in this consultation?

Agreement Checkbox Agreement Checkbox I understand this is a holistic consultation, NOT medical advice, and I accept responsibility for any potential risks.

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