Client Intake Form

 
 

CLIENT INTAKE FORM

I am 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 me, Kristina Amelong, at a charge of $1.80 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 me 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 me 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:
 

 

 
 

 
 

Describe any of the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 
Foods you eat in an average 48-hour period:

 

 

 

 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

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