Adult Intake Form

Name *

First Name

Last Name

Do you have extended health benefits for psychotherapy? If so, who is your provider? *Please note that our providers do not direct bill.

Greenshield

Manulife

Canada Life

OTIP

Other

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Yes

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about New Earth Wellness?

Social Media

Google Search

Friend/Family

Other

Has anyone assisted you previously for this concern?

Yes

No

What are you hoping to get from your session?

Pain Alleviation/Reduction

Mental Clarity

Stress Relief

Other

Metabolism:

Weight Gain

Weight Loss

High/Low BP

Blood Sugar

Thyroid

Other

Dental:

Toothaches

Tooth Implants

Root Canal

Amalgam Fillings

TMJ

Other

Digestion:

Heartburn

Abdominal Pain

Gas/Bloating

Diarrhea

Constipation

Blood in Stool

Ulcers

Colitis

Liver disease

Leaky Gut

Other

Reproductive Health:

Pregnancy

Menstrual Problems

Breast Tenderness

Breast Implants

Menopausal Symptoms

Fertility Issues

Hormone Treatment

Complicated Birth

Traumatic Birth

Prostate

Other

Skin

Rash

Eczema

Psoriasis

Acne

Botox

Other Injections

Other

Chest

Chest Pain

Palpitations

Cough

Shortness of Breath

Asthma

Other

Eyes/Ears/Mouth

Headaches

Dizziness

Ringing in ears

Blurred vision

Sinus Problems

Mouth Sores

Difficulty

Swallowing

Other

Neurologic

Numbness

Tingling

Weakness

Insomnia

Vertigo

Parkinson’s

MS

Other

Immune

Chronic Fatigue

Fibromyalgia

Yeast Infections

Viral Infections

Strep or Mono

Epstein-Barr

Lyme

Other

Urinary

Frequent Urination

Incontinence

Difficulty Urinating

Other

Sensitivity/Allergy

Medications

Chemicals

Foods

Plants

Other

Cancer

Breast

Prostate

Colon

Other

Structural

Arthritis

Bursitis

Osteoporosis

Foot/Ankle Swelling

Blood Clots/Phlebitis

Varicose Veins

Neck Pain

Back Pain

Sciatica

Other

Speech/Language

Down Syndrome

Stuttering

ADHD/Executive Function

Emotional Regulation

Hearing Loss

Trauma/Brain Injury

Slurred Speech

Other

Do you drink purified or filtered water?

Yes

No

The recommended daily water intake beginning the day before the 1st session and for 5 to 7 days after is FIVE 8 oz glasses. Do you expect any difficulty with this?

Yes

No

Do you?

Drink Coffee/Tea

Drink Alcohol

Smoke

Use Cannabis

Other Substances

Would you consider your eating habits/nutrition?

Excellent

Average

Needs Improvement

What emotionally draining relationships are in your life?

Choose any/all that apply.

Significant Other

Children

Job/School

State of the World

Relationship with Yourself

Other

Do you consider your home environment peaceful or stressful most of the time?

Peaceful

Stressful

Do you feel supported?

Yes

No

Do you have trouble concentrating or experience “brain fog”?

Yes

No

On average, how many hours of sleep do you get daily?

Less than 5

5-7

7-9

More than 9

Do you exercise regularly?

Yes

No

How active are you?

Very

Average

Not at all

Are you sensitive to light or loud noise?

Yes

No

Are you in fear regarding your health?

Yes

No

Regaining and maintaining your well being requires a strong personal commitment. How ready are you to make lifestyle, diet or attitude changes that may be necessary to good health?

Ready

Somewhat

Not looking to make changes

I have read and completed the form to the best of my knowledge and understand the questions being asked on this form are being asked to better assess my current circumstances relating to my well being. *

Yes

I further understand that I am voluntarily agreeing to having a relaxation therapy session. The services provided by New Earth Wellness are not intended to diagnose, treat, cure, or prevent any disease. *

Yes

If you cancel your appointment less than 24 hours before it is scheduled to take place, you will be subject to a cancellation fee for the full amount of the session. *

I understand the cancellation policy