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✦ Your Details

Full Name *

Date of Birth * MM / DD / YYYY

Email Address *

Phone Number

Address

✦ Why You're Here

Describe the issue(s) for which you seek help *

What are 3–5 issues holding you back in your life? For each, include a rating from 1–10 on how much it limits your life (10 = extreme limitation). Example: "I'd like to heal the pain in my leg — 7"

How would you design your ideal life? List 3–5 positive changes you'd like to see, numbered in order of importance. Example: "1. I'd like to travel to Australia." or "2. I want to have a better relationship with my son."

✦ Medical History

Past medical history Previous injuries, accidents, surgeries, etc. Please describe and include approximate dates.

Current medications Include over-the-counter medications and supplements.

Mental health diagnoses Please share any current or past diagnoses you feel comfortable disclosing (e.g. anxiety, depression, PTSD, ADHD). This helps me support you more fully.

Daily activities you're finding difficult or limited Because of the complaints described above.

Other healthcare professionals you are currently seeing For this / these issue(s).

Medical tests you've had within the past year

✦ Lifestyle & Wellbeing

How much time do you have to relax, and what do you do? Hobbies, meditation, time in nature — whatever restores you.

Do you exercise? If so, what kind and how often?

Sleep How many hours a night do you sleep? Is your sleep restful? Please describe anything relevant about your sleep quality or patterns.

Areas of pain or discomfort List each area (e.g. neck, right knee) and rate discomfort from 1–10, where 10 is worst.

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Thank you for sharing.

Your intake has been received. I look forward to holding space for your journey.

Welcome to Illuminated Pathway

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