Intake Form | Earth Horse Healing

Human Intake

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.

General Information

Name(Required)

First

Last

Phone(Required)

Please provide the phone number you will contact me from.

Email(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Appointment Scheduling: Eastern Time(Required)

Mon-Fri 11:00 am

Mon-Fri 2:00 or 3:00 pm

M-Fri 7:00 pm

Please select the times you are available, Eastern Time.

Appointment Type Requested(Required)

FaceTime

Phone

Zoom for outside the USA, Canada, and Puerto Rico

Presenting Issue(s)(Required)

Date of Onset(Required)

Initiating Cause(Required)

Contributing Factors(Required)

Previous and Current Treatment for Above(Required)

Current Medications/Supplements(Required)

Lifestyle

Occupation & Lifestyle(Required)

Employment, child rearing, caregiver

Physical Exercise(Required)

Please list activities and amount of time you engage in them per week.

Allergies & Sensitivities(Required)

Food and environment. Are you on a special diet?

Please describe any regular use of alcohol, recreational drugs, or tobacco(Required)

Daily, weekly, occasionally

Medical History

Please list any significant injuries or accidents you've had.(Required)

Any mental or emotional issues presently in the past? Depression, anxiety, eating disorders, or substance abuse?(Required)

If so, include any diagnosis and current medications.

Do you have any cardiovascular/heart related health issues?(Required)

High/low blood pressure, disorders, heart attacks, past surgeries, pacemaker, etc.

Please list any other medical history and/or issues I should be aware of:(Required)

Year of Birth(Required)

Healing Session Preparation

What are your passions and Vision for your life?(Required)

What would you like to change as a result of your healing session?(Required)

How did you hear about Ginger and Earth Horse Healing?(Required)