Confidential Client Case History and Intake Form

Name *
Phone Number *
Phone Number
Date of Birth: *
Date of Birth:
Do you suffer from any of these conditions (past or present)? Check all that apply
Do you experience any of these symptoms? (Please check all that apply)
Which areas would you like improvement in? (Please check all that apply)
I consent to treatment for myself and understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan. I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I understand that only the practitioner Tanya Page will have access to information in my file to enhance my healing. I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless the practitioner Tanya Page. *