By taking a few moments to complete this form, you are on your way to feeling better. The information you provide here is completely confidential and will give me a better understanding of your current health issues and the past and present experiences that contribute to your health and well being. Best of all, this form initiates the process of setting appropriate goals to get you feeling healthier in body, mind, heart and spirit.

The more information you can provide, the greater value this form will have for me to help you.
 
 
 
I value your privacy. All information collected will be kept strictly confidential.

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