Client Intake Form

 
 

Secure Client Intake Form

I am happy to help you with any part of your healing program! By submitting this secure intake form, you are setting your intention to have a phone consultation with me, Kristina Amelong, at a charge of $2.25 per minute.

IMPORTANT! Please ensure that you have a stable internet connection when completing this online form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.)

Any supporting documents can be attached at the bottom of this form if desired.

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

 
 

 
 


 
International clients only: How would you prefer to call Kristina? Check one:
 

 


 

 

 



 (mailing address required)

 

 

 

 

 

 

 
 
Foods you generally eat in an average 48-hour period:

 

 

 

 

 
 

 
 

 
 

 
 

 
 

 
 

PLEASE NOTE: The remaining sections of this form are all OPTIONAL. Complete only the sections that you feel are relevant to your consultation.

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

 

 
 

 
 

Describe any of the following if relevant:

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 
Check all of the health challenges you would like help with:
 

 
 

 

 

 


 

 

PERMITTED FILE TYPES: jpg, jpeg, png, gif, pdf, doc, docx

PLEASE NOTE: Maximum file size permitted is 3MB. If you are unsure whether an attachment exceeds 3MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email your photo to me at kristina@ optimalhealthnetwork.com.

 

 

 

 

NOTE: OHN Hair Tissue Mineral Analysis (HTMA) test results do NOT need to be submitted with your intake form.




 

PERMITTED FILE TYPES: pdf, doc, docx, txt, xls, xlsx, odt, ppt, pptx, jpg, jpeg, png, gif

PLEASE NOTE: Maximum file size permitted is 3MB per attachment. If you are unsure whether an attachment exceeds 3MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email any supporting documents to me at kristina@ optimalhealthnetwork.com.

 

 

 

IMPORTANT:

Submission of this form may take up to 30 seconds after the Submit button is clicked. Thanks for your patience. Please do not refresh the page or use the back button!

 

 

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