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Contact Information
Full Name *
Birth Date - YY/MM/DD *
Mailing address
Phone Number *
Email *
What kind of session would you like to have? Private in Person Online via Skype *
Your Skype ID for online session
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Questions about your problem. If you can't answer, skip the question.
What is the problem? What do you have and do not want to have?
How do you know that you have the problem?
How will you know that the problem is solved?
Where, when, how does your problem become apparent?
What methods or medication have you tried to solve your problem?
What are the results of using these methods or medication?
What do you not have and want to have?
What do you have and want to have? (Think of what can help you)
What do you not have and do not want to have?
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Additional health questions. If not applicable, leave them blank.
Height and weight
Family health history
Did you have any surgery, injury or trauma?
Did you experience any stressful events?
Smoking or use of drugs?
Additional notes or comments?
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Thank you for submitting your form.
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