New Client Form - Part 1 - Finding Source

New Client Form Part 1

The New Client form below is for anyone requesting an appointment with Gary for the first time. Please take the time to fill this form out completely.

> Client Responsibility & Wellness Disclaimer > Informed Consent Information Here

My services are educational and wellness-oriented in nature and are not intended to replace medical diagnosis, treatment, emergency care, or the advice of a licensed medical provider. Please consult an appropriate qualified healthcare professional regarding medical concerns, diagnoses, medications, or emergencies.

Your health and well-being are ultimately your responsibility. Meaningful change requires your active participation, willingness to recognize patterns, and consistent implementation of the recommendations, lifestyle adjustments, and self-care practices we discuss. I can provide education, support, and guidance, but I cannot make changes for you. If patterns are ignored and no action is taken, results are unlikely to change.

Part 1

- Info icons are next to some questions for better clarification

Contact & Preliminary information

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Age *

What is your occupation/work schedule? *

> I have fully read the Client Responsibility & Wellness Disclaimer statement above and give my full consent *

Yes

> Do you have a Gift Certificate or Voucher? *

Yes - I paid through this Website Yes - I was gifted a session No - I need to purchase one

> Full Name of the Person who purchased your Gift Certificate *

> If you have a Referral - Who referred you? *

> How did you Find me? *

Main Concern & Goals

1. What are your primary concerns that you need help with? *

2. When did each concern begin? Was there an event, illness, injury, stressor, or life change around that time? *

3. What makes the concern better or worse? *

4. What have you already tried: Medical care, herbs, supplements, bodywork, diet changes, therapies, etc.? AND has anything specific helped so far? *

5. What are your top health & wellness goals for the next 3-6 month *

6. Two part question: On a scale of 1–10, how important is making changes right now? AND How confident do you feel that you can follow through? *

Part 2: Comprehensive Health & Lifestyle Questionnaire
This optional form gathers additional information to help identify deeper patterns and provide a more complete understanding of your overall wellness picture, beyond what was shared in Part 1. Please complete this form only if you would like a deeper perspective on your concerns or if it has been requested prior to your appointment. After signing below and submitting this form (Part 1), go back to the main email page and select Part 2 or follow the prompt in the confirmation page after submitting this form.

Digital Signature & Confirmation Section

> I have read, understand, and agree to the Client Agreement, Informed Consent, Assumption of Risk, and Release. I consent to the use of an electronic signature. By submitting New Client Form Part 1 and, if I choose to complete it, New Client Form Part 2, I confirm that typing my legal name constitutes my electronic signature and indicates my agreement to the documents listed.

Confirm Above Statement *

Yes

Type your Full Legal Name *

Digital Signature Date: *

> Please make sure you get a Confirmation page after submitting this form. If you do not, then try resubmitting to make certain it has gone through.

Submit

New Client Form Part 1

Part 1

General Info

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