EmailMeForm
Client Intake Form
Thank you for taking the time to fill in this form prior to your appointment. I can assure you that your information is safe and will not be view by anyone outside of Shamarie's Body & Mind Therapies. Filling in this information prior to your appointment will enable me to spend more time helping you heal rather than gathering all the information I am required to obtain. Collecting your case history information is a vital part of your healing and I will also be seeking more in depth information during your appointment.
Email
*
Confirm
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Current Age
*
Date of Birth
*
DD
/
MM
/
YYYY
Mobile Number
*
Home Phone Number
Preferred Contact Method
*
Mobile
Home Phone Number
Email
Occupation
*
Next of Kin
*
Relationship Status
*
Single
Married
Separated
Divorced
Partnered
Widow
Do You have Private Health Insurance?
*
Yes
No
Private Health Insurance
*
Doctors Name
*
Doctors Telephone Number
*
Number of siblings and your position in the family?
Number of your children and their ages?
Other Therapists and therapies currently engaged
Drugs and supplements currently taken
*
If you are not currently taking anything just enter "none"
Known Allergies
*
Have you ever completed a detox program before and when was the last time?
Do You have High Blood Pressure?
*
Yes
No
Do You have High Cholesterol?
*
Yes
No
Do You have breathing difficulties?
*
Yes
No
Do You have a Diagnosed Mental Health Condition?
*
Yes
No
Do You have a diagnosed medical Condition?
*
Yes
No
What is the medical name of your mental health condition or other medical condition?
*
If you have no diagnosed medical condition insert None
Your main reasons for consulting with Shamarie
*
How did you find Shamarie's Body & Mind Therapies
*
Image Verification
Please enter the text from the image:
[
Refresh Image
] [
What's This?
]
Powered by
EMF
Contact Form
Report Abuse
