Human Follow-up Form

Please fill out and submit this form at least 48 hours prior to your initial appointment. The information you provide is held as private and will not be shared without your expressed permission.
  • Contact Information

    Please update your contact information, where necessary. Only the fields with a red asterisk are required.
  • Previous Session Results

    Please tell me about any significant improvements you have experienced as a result of our last session.
  • Current Condition

    Any health issues that you have going on presently.
  • Be sure to distinguish any new health issues that have presented since our last session.
  • Please include an update of the previous medical diagnosis plus any new diagnosis you have had since then.
  • Please specify what each medication is for and duration of treatment.
  • Lifestyle

  • Healing Session Focus

    Please take the neccessary time to consider the following question.