Intake Questionnaire

Please fill out the following form to help us understand your current state.

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Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
are you under the care of a doctor?
Are you under currently working with a Counselor?
do you have a sking condition or Allergies
Do you currently or in the past 12 months have done the followng
what is your normal body temperature?
In case of an emercency,would you like me to call anybody?

If no, please be advised that I will call 911 in case of an emergency

Thanks for submitting!