Adult Health Assessment

As a new client, I am thankful that you’re here and I sincerely look forward to working with you. A chunk of time during your first session will be spent discussing your life and family history and it will save a lot of time if you can complete the history assessment prior to your session. Simply fill out the form below. It should take about 10 – 20 minutes and would be easier to complete on a computer as opposed to a mobile device.

New Client Form

Please complete this Wellness History Form and submit via email at least 3 days prior to your session. Should you have any questions, please note that in the Additional Comments section.

Is this a new or recurring issue?

List with approximate date and/or age past trauma that you've experienced in your life to include emotional, physical, mental, spiritual etc.

Emotional Trauma: such as someone dying: animal or person, a divorce: yours or your parents, losing a job, not getting a promotion, the breakup of any close relationship - friend, family, or life partner, abuse

Physical Trauma: accident or illness: events such as concussions, falling off a swing when young and hitting your tailbone, definitely include all surgeries and broken bones. Also include illness of close friends, family, animal companions, addictions in the family, etc.

Mental Trauma: Overwhelmed with too many bases to cover, financial trauma, a lot of criticism or judgement in childhood, alcohol, drug, gambling addiction in the family causing children to have too much responsibility too soon.

Spiritual: loss of faith, why me?

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