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New Client Intake Form

*In order to devote more time for treatment, during your first

appointment, please complete the below forms and press the SUBMIT tab.

*Alternatively, you can press the PRINT form tab and complete them

manually before you come to the office or wait to complete them on your

first office visit.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please enter a number from 0 to 100.

  • PAST MEDICAL HISTORY​

  • I hereby certify that my answers are accurate to the best of my knowledge. I acknowledge that providing inaccurate information has the potential of being detrimental to my health. If I ever have a change in my health, I will inform Graceful Healing LLC on or before my next appointment. By submitting this New Client Intake Form, I consent to the Terms and Conditions outlined on this website under the below link: Terms and Conditions