HearthsideHealing.com

Jon Keyes, LPC, Licensed Therapist and Herbalist

New Patient Intake Form

 

 

Name:

Birthdate:

Address:

Email address:

Telephone:

Insurance Information (Name of insurer, policy number, policy phone number):

Relationship Status/Children:

Occupation/Hours of work per week:

Please list your main goals for counseling:

 

 

Please list any health concerns:

 

What medications/herbs/supplements do you take?

 

Do you sleep well? How many hours?

 

Are you in physical pain? Where and for how long have you had it?

 

Allergies or sensitivities?

 

Any healers, helpers or therapies with which you are involved? Please list:

 

How much do you exercise a week and what kind?

 

What is a typical meal plan for you during the day?

Breakfast:

 

Lunch:

 

Dinner:

 

Snacks:

How much water do you drink a day?

Typical Caffeine drinks/day:

Typical alcohol and/or marijuana consumption:

Other drug use:

Hobbies/interests:

Long Term Goals Life goals: