. Patient Enrollment Form Patient Enrollment Form I. Patient Information Full Name Date of Birth Gender Identity Female Male Non-binary Other Preferred Pronouns Marital Status Select Single Married Divorced Widowed Occupation Employer II. Contact Details Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number IV. Referral Information How did you hear about us? Website Social Media Friend/Family Practitioner Event Other V. Health Information Are you currently under the care of a physician or mental health professional? Yes No If yes, please explain Are you taking any medications or supplements? Yes No If yes, please list Have you had any recent surgeries, diagnoses, or major health concerns? Yes No If yes, please describe Are you currently pregnant? Yes No N/A Do you have a history of (check all that apply): Chronic Pain Anxiety Depression High Blood Pressure PTSD Autoimmune Disorder Cancer Diabetes Other VI. Wellness Goals & Intentions What brings you in today? Feel free to be as detailed as you'd like Primary goals for our sessions (check all): Stress Relief Emotional Healing Pain Management Spiritual Connection Chakra Balancing Energy Clearing Chronic Dis-Ease Management Autoimmune Dis-Ease Relief Other VII. Consent & Acknowledgement I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns. I give permission to be contacted for appointment reminders, wellness updates, or follow-ups. Signature Date Submit
