Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Name or nickname you prefer if other
Preferred pronouns?
City
*
Best phone number for me to reach you at.
*
(###)
###
####
Mobile phone
(###)
###
####
Are you reachable by text
Your email address
*
What is your profession(s)?
Age
How did you hear about me?
Briefly explain your exercize/fitness regimen.
Care to briefly share your spiritual, philosophical, or religious orientation?
What are the major stressors in your life?
Are you currently working with a therapist or counselor?
Are you currently under a physician's care for medical conditions? Please explain.
What do you want to change or improve with this treatment?
Have you been experiencing any of the following during the past year?
Other health conditions not listed above.
Are you currently taking prescription medications?
List all surgeries with approximate dates
List concussions and major head injuries, if any, with approximate dates
List other significant injuries with approximate dates
Rate your quality of sleep from 1(terrible)-10(perfect) and explain if you like.
Rate your energy level from 1(terrible)-10(perfect) and explain if you like.
Do you currently have any of the following?
Check box if pregnant
Is there anything else you think may be helpful for me to know?
I agree to give at least 24 hours notice should I need to cancel or reschedule a session, and pay for sessions cancelled or missed without such notice.
*
Terms and Conditions
*
Ko Darlington is not a licensed medical doctor nor licensed psychologist and does not practice any form of licensed medicine or psychology. He does not diagnose, cure, heal, treat disease or prescribe medication. He will not be held responsible for any damages or losses. It is recommended that clients continue to seek the advice of a licensed physician for medical conditions.
