Wellness Care
Please fill out the intake form below. You can always change your mind later but for now I want to hear a little about you. Please answer to the best of your knowledge today and know you will have time to tell me more as we build a foundation of trust. 
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Email *
Name *
Partner name(s) *if not partnered please list n/a
Email *
Address *
Phone number *
Name of PCP (Primary Care Provider) if none list n/a *
Name of any other healthcare providers you see regularly and their title (Ex: TCM, acupuncture, massage, chiropractic...) If none list n/a *
List any groups you identify with? (Ex: LGBT/BIPOC/Disabled) *
What kind of care are you seeking? *
What goals do you have for your care? *
Who/what are your support systems? (ex:friends, family, savings, pets...) *
How did you hear about us? *
What are 3 good days and times for a 15-30 min consultation? (ex: Tuesdays 1-530pm) *
You Made it! I know these things aren't always fun
Once I have received your intake I will contact you within 48 hours to schedule a consultation with me. During our consultation I will tell you more about me and the care I provide, go over starting care and you can ask me questions.
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