Confidential Client Case History + Intake Form
In the space below, please list your current symptoms:
Please grade your current symptoms with 1- 'hardly noticeable' to 10 - 'symptoms are unbearable':
Please list any significant accidents/injuries/operations past and/or present:
Please use the space below to list any medications/vitamin supplements that you are currently taking:
Please check the box below if you have currently, or have had in the past any of the following health conditions:
Current + Past Health Conditions
Please use the space below if you are experiencing any other physical or emotional symptoms:
Please describe what you would like to accomplish from your sessions with Six Alchemy: