Introspective Odyssey

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Consultation
Terms & Agreements, Intake Form & Waiver

Email *

Please note that some sessions are conducted by Ruba Moghraby, some by Nick Nelson and some sessions are conducted by both Nick & Ruba. Therefore, this agreement uses "Nick&Ruba" to mean Nick and/or Ruba. You will find that there is repetition in this Terms & Agreement form. There are several pages to this online form. Not all questions are mandatory. Make sure you complete this form all the way through and hit send. *

Check this box to indicate the you have read, understand and agree.

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First and Last Name *

Phone Number *

The above phone number provided is a *

Mobile Number (receives texts)

Land line and does not receive texts

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Address

Date of Birth *

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Gender (Identify as)

Female

Male

Other:

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Marital Status

Number of Children

Profession and duties

How did you come to know of Nick&Ruba and what we offer?

If you have been under a doctor's care this past year, please explain.

Have you had any prolonged illnesses or physical problems?

If you are currently taking any medication, please list and explain.

What is the main reason you are seeking sessions with us?

Is there anything else you would like Nick&Ruba to know?

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