Session Intake Form

This is a secure form and confidentiality is assured. If you prefer to keep some details private until you meet or speak with Dave, feel free to be very brief here or leave some things blank.
Another option is to download the intake form here, fill it in, and email it to [hidden email].

First Name:
Last Name:
Preferred email:
D.O.B: (mm/dd/yyyy)
Address Street:
City / State / Zip / Country:
Preferred phone number you'd like
to be called on, or Skype address:
(We use Skype for calls outside North America):

Occupation:
Who can we thank for your referral?
(Please be specific.)
Briefly describe any physical / emotional / energetic health challenges in order of priority:
700 character limit
Briefly describe types of modalities
already tried and their results:
700 character limit
Diet:
Do you...
(yes/no - briefly elaborate):
 
Smoke:
Drink:
Exercise:
Meditate:

Are you currently or have you ever been diagnosed with a mental disorder?
If yes, please explain in detail:

700 character limit
Briefly describe your spiritual beliefs:
700 character limit
Relationship status:
What is your intention a/o
goal from your upcoming
session(s)?
700 character limit

If you have already scheduled your first appointment, please list the date and time here (include time zone):

What brings you joy?
700 character limit
To achieve the best energetic connection, please choose one option below:
Option A:
Provide a URL that features your photo (Facebook page, website, etc.)
Option B:

Upload a photo (JPG, GIF, etc. - filesize under 8Mb)

Option C:
I prefer not to send an image at this time.
  To be kept in the loop about events and helpful articles for better living, may we sign you up for the newsletter/event reminders? Your information will never be shared or sold in any way, and you can always opt out at any time.
Newsletter Signup:

I certify that:

  • I have read the disclaimer below;
  • the above information is true, honest, and that nothing pertinent (e.g. mental diagnoses, etc.) has been omitted;
  • that I am 18 years of age or older; (If the information entered above is for a minor, click here to indicate such and that you as legal guardian approve of this and any follow up sessions.)
  • and that I am responsible for the scheduled time. If I cancel less than 24 hours prior to my appointment or no-show, full payment is required.
Electronic Signature:
Date: 07/23/2021
Prove you're human:
How many sides does a square have?

(SEND on next page)

Disclaimer:
These concepts are not intended to diagnose, cure, prevent, or treat your symptoms, disease, diagnosis, illness, or alike, or replace your medical treatment in any way, shape, or form. Dave Markowitz, the web-designer/hosting company, book editors/distributors/publishers, Paypal, and so on make no medical claims whatsoever and assume no liability of any kind for the (mis)interpretation or (mis)implementation of this text, written, spoken or implied. Simply use what resonates with you and discard the rest. Remember, it's always best to appreciate, and heed the advice given by, 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.