Auriculotherapy Intake Form
The outer surface of the ear is a microsystem of the entire body and contains over 200 acupressure points. When these points are stimulated, messages are sent from the brain through nerve pathways to promote homeostasis to the corresponding area of the body, including emotional regulation.

I will present a customized protocol based on your current state, and guide you through the application of your ear seeds during an online consultation.

Because auriculotherapy works cumulatively, it is recommended to also schedule tune-up treatments to track your progress and make any necessary adjustments to your protocol.

Please complete this form, with the understanding that all information is kept confidential.
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Email *
Today's Date
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Name
Age *
Complete Mailing Address
Mobile Phone
Email Address *
Main Condition Seeking Treatment: *
Secondary Condition (if any):
Known Sensitivity to Latex? *
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