Heal Better — Intake Form

This helps us prepare for your session. Take your time — your answers go directly into our clinical system. Nothing is shared.

1. Who & What

The basics — who you are and why you're here.

Full Name Email In one sentence, what's your main health concern?

2. The Story

When did this start? What was happening in your life right then?

When did the symptoms first appear? What was happening in your life at that time? (events, changes, stresses) How has this affected your life?

3. What You've Tried

Who have you seen? What worked, even a little? What didn't?

Practitioners or modalities you've tried What helped, even temporarily? What made things worse?

4. The Body

Where is it? What does it feel like?

Where in your body is the main symptom? Describe the sensation What makes it worse? What makes it better? Does it have a rhythm? (time of day, seasons, cycles)

5. The Patterns

What emotions or thoughts keep showing up with this?

What emotions do you feel when the symptom is active? Are there recurring thoughts that come with it? If this symptom were gone tomorrow, what would be different in your life?

6. The Moment It Started

If you can identify a specific moment or event that triggered this, describe it.

Do you remember a specific shock or event around the time this began? How did you feel in that moment, physically and emotionally?

7. Your Birth Details

This helps us map your unique biological architecture. Optional but powerful.

Birth Date

Birth Time

Birth Place

✓ Received

Your intake has been processed. We'll review it before your session and come prepared with a plan. See you soon.