Work With Me
>> the sacred divine feminine
Work With Me
Confidential Client Case History and Intake Form
Date of Birth:
Date of Birth:
What are your primary concerns? Please indicate level of concern. Level: 1(hardly notice symptoms) to 10 (symptoms are unbearable)
Please list any Medications/Remedies/Supplements & Reason for taking:
Any significant accidents/injuries or surgeries?
Do you suffer from any of these conditions (past or present)? Check all that apply
High or Low Blood Pressure
Do you suffer from any genetic disorders or phobias (past or present)? Please specify.
Do you have any known allergies (past or present)? Please specify.
Please list any conditions that run in your family, or that your parents or grandparents experienced. (ie., various cancers, heart disease, depression, etc.)
Do you experience any of these symptoms? (Please check all that apply)
Tightness in Jaw
Weak body parts
Grinding of Teeth
Heavy feeling in limbs
Blurriness of vision
Loose Bowel Movements
Pains in heart/chest
Cold in hands and feet
Lower Back pain
Carpel tunnel syndrome
Are you pregnant?
If you selected 'Other' please specify:
Do you smoke? If yes, how many cigarettes per day?
Which areas would you like improvement in? (Please check all that apply)
Negative self-talk, self-sabotage
Belief in ability to achieve goals
Ability to relax
Ability to use dreams as mental tool for problem-solving
Ability to reach ideal weight
Breaking old habits
Release negative events
Ability to align body/mind for self-healing
Ability to take action
Increase learning ability
Prosperity (attract what you choose)
Attitude and skills at work
Please list any and all other conditions or symptoms that are not noted in the above questions.
Below, please describe what you would like to accomplish with these treatments?
I consent to treatment for myself and understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan. I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I understand that only the practitioner Tanya Page will have access to information in my file to enhance my healing. I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless the practitioner Tanya Page.
I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct.
Please Click Here to schedule a date/time for your appointment.
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