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Health Assessment Form

This form is not necessary to fill out until after speaking with a member of our team. To start that process, please contact us.

 

Please fill out this form completely and be as thorough and honest as possible. This is for your safety so we made provide the most successful treatment possible.

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*All fields below are required.

Do you now or have you had a problem with any of the following? Check all that apply. Required
Do you consume coffee? Required
Do you exercise regularly? Required
Do you now or in the past experience any of the following? Required
Have you experienced any of the following? Required
Have you experienced any of the following losses? Required
Do you engage in any of the following forms of self harm? Required
Is the medicine calling you? Required
How spiritually healthy do you feel?How spiritually healthy do you feel?
How physically healthy do you feel?How physically healthy do you feel?
How mentally healthy do you feel?How mentally healthy do you feel?

Thanks for submitting!

We’ll get back to you shortly.

Ready to learn more?

Please leave us a detailed message and we will send you an email with more information, and the details to schedule a call.

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