Client Intake Form

 
 

CLIENT INTAKE FORM

We are happy to help you with any part of your healing program. By submitting this intake form, you are setting your intention to have a phone consultation with one of the Optimal Health Network staff, at a charge of $1.60 per minute.

** IMPORTANT: Please ensure that you have a stable internet connection when completing this form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.) If you would prefer to mail us a printable PDF version of this form, please click here.

The Optimal Health Network respects the privacy of its clients. All personal information provided on this form will be held in strict confidence and will not be released to any third party without prior written authorization.

 
 

 

 

 

 

 

** IF POSSIBLE, please also e-mail us a complete blood count (CBC) test from your medical doctor.

 

 

 
Check all of the following challenges you have now or have had in the past: