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Forms

       New Client Forms

1.  Please print and then fill out the New Client Information Form. 

2.  Fill out the Autonomic Nervous System Questionnaire on your computer.  Your answers will generate a graph. Print ONLY the Graph. 

 
3.  Bring the completed Information Form and the Nervous System Graph with you for your first session.  
 
If you are unable to print out the forms, please contact us in advance so will be able to expect your early arrival and accommodate you. 
Plan to arrive at least 20 minutes prior to your scheduled appointment time in order to fill out the New Client Information Form.  
 
If you do not arrive early, the time taken to fill out your form is included within your scheduled appointment time, and will therefore result in a shortened appointment. 
 
Completion of the New Client Information form is required for all clients, and we will not perform any services without a full health intake and liability release.  It is strongly recommended that you also fill out the Autonomic Nervous System Questionnaire and Graph so that your therapist will know best how to work with any high level issues in your nervous system.

Please read our policies, and be sure to SILENCE your cell phone upon arrival by turning it OFF or putting it on DO NOT DISTURB mode.

 

New Client Information Form

Autonomic Nervous System Questionnaire and Graph

       Insurance Information Form

This form walks you through the information you will need from your insurance company for possible re-imbursement if you choose to call them.  We do not bill insurance, and we are considered out-of-network providers.  Most insurance companies require that your in-network deductible and out-of-network deductible are met before they will consider any re-imbursement.  
 
You do not need to bring this form with you to your appointment.  
       Looking for a Gift Certificate?

Gift certificates are available in our office.  You can come by and purchase one in person, or you can call to purchase over the phone.  We can mail the certificate to you, to the recipient, or hold it here in our office.  Please view the policies page for details about gift certificates.
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