Intake Form

Download the Client Intake Form to fill out at your convenience.

In-depth Client Intake Form

The investment for this 2-part process is $175

To help solve your health challenges through food and lifestyle modifications, I need to know your unique story. Your bio-individuality, such as family history, and the main events in your life that have shaped who you are, beyond food choices.

Maybe that little bump on your head years back triggered a series of health issues shortly after. Or living near that apple farm for two years, where pesticides were sprayed affected your nervous system.

This is where you begin to connect the dots between your health and events in your life. Our sessions will be based on this information. Take your time and make a cup of tea while filling it out.

How it works

Part One

  • Download the interactiv pdf of the  Client Intake Form or complete the form below (same questionnaire)
  • Email the completed form back to me
  • Schedule your 90-Minute Review Session on my calendar
  • We’ll review your information by phone or online

Part Two

  • I create a timeline based on the information from your intake form
  • We modify this timeline as we work together
  • You’ll receive a Functional Nutrition Matrix that captures your symptoms and experiences
  • You’ll be able to share this timeline with your doctors too!


If you have any questions please email me. The secure PayPal payment can be made on my purchase page.

Thank you!

  • Confidential Client Information

  • Statistics

  • History

  • Health Concerns

  • Nutritional Status

  • Intestinal Status

  • Medical Status

  • Health Hazards

  • Lifestyle History

  • Sleep History

  • For Women Only

  • Sexual History

  • Mental Health Status

  • Other

  • Forms of relaxation

  • Food

  • Other

Thank you for taking the time to fill out this form and for your payment!

I look forward to talking soon.