Thank you for taking the time to chat with me about your health situation. I am glad that you're willing to share your experience with me, and I hope I can take this information and create a way to serve you in the highest way possible. 

Please answer any questions below that are helpful in describing your situation. Some of them might not fit, so feel free to skip anything that doesn't make sense for you.

Please note that this form is not considered a secure transmission source for protected health information.  If you include your name and contact information, this data will be personally identifiable. I will take extensive precautions to secure your information. I cannot guarantee that it will not be intercepted during transmission. 

If you wish to send me this information securely, you can use to send a secure email. Send it to info @

Consider physical, emotional, social, or spiritual impacts.
It is completely ok to have no answer to this question.
What kinds of changes would you be willing to make to improve your health?
If you would like for me to contact you, please also include your name and email/phone here.