Intake form

Name *

Email address *

What is your primary reason for seeking integrative health services?

Please select at least one option.

Chronic pain management

Mental health support

Nutritional counseling

Lifestyle coaching

Preventive health care

Alternative medicine

Please specify any medical conditions you currently have or have had in the past.

What medications are you currently taking?

Do you have any allergies? if yes, please specify.

What is your preferred method of communication?

How did you hear about us?

What is your primary goal for treatment?

Please select at least one option.

Improve overall health

Manage a specific condition

Enhance mental well-being

Increase energy levels

Achieve weight loss

Improve nutritional habits

Do you have any specific lifestyle habits or routines that impact your health? please describe.

What is your current level of physical activity?

Are you currently seeing any other healthcare providers? if yes, please specify their specialties.

Which service or services are you interested in?

Please select at least one option.

Integrative Massage

CranioSacral Therapy

Women's Therapeutic Massage

Lymphatic Therapy

Gentle Healing For Children

SomatoEmotional Release (SER)

Deep tissue therapy

Swedish relaxation

Sports recovery

Relaxation massage

Sports massage

Additional questions or comments

HealOne BodyTherapeutic Massage & BodyWork