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 $1.80 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.) If you would prefer to complete a printable version of this form and mail it to me, please click here.

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.

 
 

 


 (mailing address required)

 

 

 

 

 

 

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

 

 
 

 
 

Describe any of the following if relevant:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

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

 

 

 

 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

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

 
 

 
 

 
 


 

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 2MB per attachment. If you are unsure whether an attachment exceeds 2MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email any supporting documents to kristina@ optimalhealthnetwork.com.

 
 

[recaptcha]

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.