Please fill out this form as part of the intake process. The information we collect through this form helps us gain a detailed understanding of your health and a holistic understanding of you as a person. This is critical for us to provide you with personalized, evidence-based, and high-quality care.

All information you enter into this form will be kept strictly confidential and private. This electronic form is HIPAA-compliant and the information is stored in a HIPAA-compliant, encrypted database.