| Name (Last, First): |
|
| D.O.B: |
(mm/dd/yyyy) |
| Primary email: |
|
Secondary email if
primary is not working: |
|
| Address: |
|
| City / State / Zip: |
|
Primary phone number you'd like to be called on,
or if we'll be using Skype, your Skype address: |
|
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: |
|
Are you currently
or have you
ever been diagnosed
with a mental disorder?
If yes, please explain in detail: |
|
|
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:
(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 |
| Best times for you: |
|
|
In-person hours
in Portland Oregon:
(ALL TIMES ARE PACIFIC)
|
| Mondays: |
2pm to 7pm |
| Thursdays: |
1:30pm to 5pm |
| Best times for you: |
|
|
| What makes you happy? |
|
|
| Typed Signature: |
|
| Date: |
05/17/2012 |
|
|
(submit on next page) |
Disclaimer:
Sessions are not intended to diagnose, cure, prevent, or treat your symptoms, disease, illness, or alike, or to diagnose or replace your medical treatment in any way. Dave Markowitz, and affiliates thereof make no medical claims whatsoever and assume no liability of any kind for the (mis)interpretation or (mis)implementation of the content of your session, either spoken or implied. Simply use what resonates with you and discard the rest. Remember, it's always best to see (and hug) your Doctor.
Dave Markowitz reserves the right to decline to work with anyone who he deems as an inappropriate match for his services at any time. |