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ONLINE CLIENT INTAKE FORM..pre-session-first visit

Please Fill out the form below before your first session. Your information remains confidential and is submitted directly to Lorri Ann Stewart. It will be utilized only to prepare and customize your session. Then be kept on file with notes for each follow-up session. If you do not wish to share on form, it is totally optional!! ;)

First Name
Last Name
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
E-Mail
Sex
Marital Status
Date of Birth
Place of Birth
Emergency Contact
Referred by
Number of Siblings
Sex and ages of Siblings
Spouse’s Place of Birth
Number of Spouse’s Siblings
Sex and Age of Spouse’s Siblings
Have you ever had Counseling
Are you on any medications?
List all medications
Are you currently under the care of any health care professional?
Explain
Do you frequently suffer from stress?
Do you experience frequent headaches?
Have you ever been in an accident? Please include DATE.
Briefly detail any major physical, mental, or emotional occurrences in your life.

Any surgeries? Include Date(s)
Intention or Goals for session?
Please tell me about any types of yoga, meditation or holistic health treatments from types of bodywork to any energywork you have experienced before! Anything you would like to share?
Are there any conditions I should be aware of?
Explain
Please use this area to explain in detail anything you feel you need to:

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