Online Client Intake Form

 

Peggy Reynolds-Olsen
227 N. El Camino Real Suite 103
Encinitas CA 92024
(760) 809-7081

First Name Last Name Street Address City State Zip Home Phone Work Phone Cell Phone E-Mail Sex Marital Status Married Single Divorced Widowed/Widower Please Choose Date of Birth Place of Birth Emergency Contact Referred by Number of Siblings Sex and ages of Siblings Spouse’s Place of Birth Number of Spouse’s Siblings Sex and Age of Spouse’s Siblings Have you ever had Counseling Please Choose Yes No Are you on any medications? Please Choose Yes No List all medications Are you currently under the care of any health care professional? Please Choose Yes No Explain Do you frequently suffer from stress? Do you experience frequent headaches? Have you ever been in an accident? Please include DATE. Briefly detail any trauma occurence in your life; death, accidents, war, attack. Any Fall? Include Date(s) Any surgeries? Include Date(s) Intention for coming? Please tell me anything you know about your birth, were you born in a hospital or at home? Was it Vaginal? Was your mother under anesthesia? Did you spend time in an incubator? Were you breast fed? Are there any conditions I should be aware of? Explain Please use this area to explain in detail anything you feel you need to:

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