Client Initial Intake Form

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Name (Last, First):
D.O.B:		(mm/dd/yyyy)
Address:
Primary email:
Secondary email if primary is not working:
Phone number you'd like to be called on:
Secondary phone number if primary is not working:
Occupation:
Referred by:

Health concerns, in order of priority:
Types of modalities already tried; results:
Please describe your diet:
Do you (yes/no - elaborate):
Smoke:
Drink:
Exercise:
Meditate:

Please describe your spiritual beliefs:
Please describe your relationship status (current/prior):
What is your intention a/o goal from your upcoming session(s)?
Phone hours are (ALL TIMES ARE PACIFIC): Mondays: 9am to 11am Tuesdays: 9am to 11am, and 2:30pm to 5:30pm, and 8pm to midnight Wednesdays: 9am to 11am, and 2:30pm to 7:30pm Fridays: 9am to 11am, and 2:30pm to 5:30pm
In-person hours in Portland Oregon are (ALL TIMES ARE PACIFIC): Mondays, 2 to 7pm Thursdays, 1:30 to 5pm
What makes you happy?
Disclaimer: Any presentation of any concepts by Dave Markowitz, including but not limited to the book text, web-text, magazine articles/columns, lectures, workshops, or private sessions are not intended to replace any existing modality of healthcare. Neither Dave Markowitz, nor the hosting facility, book/magazine publishers, book/magazine distributors, book/magazine sellers, owners, employees, assistants, or volunteers of the hosting facility, book/magazine or marketing/distribution related business or Dave Markowitz can be held liable in any way for the (mis)understanding or (mis)application of the concepts discussed, implied, demonstrated, or presented through the aforementioned and any other medium. By signing/initialing below, you acknowledge your answers to the above questionnaire are true, you have read and understand the Disclaimer, and that you are aware there is a full-responsibility, 24-hour cancellation policy.
Name / Initials:
Date:		(mm/dd/yyyy)

Above Photo © Keith Jacoby. Used with permission.
Unauthorized reproduction is prohibited.

Healing with Source symbol used by permission from Janet Cristenfeld