Client Intake Form

Client Intake Form

    Preferred Contact Method


    Relationship Status


    Do You Have Private Health Insurance?


    Do You Have Any Of The Following?

    High Blood PressureBreathing DifficultiesDiagnosed Medical Health ConditionDiagnosed Mental Health ConditionNone of the above

    How Did You Find Shamarie ?

    Google SearchNatural Therapies PagesOther InternetReferred by a FriendFaceBookOther

    If you have filled in this form before making your first appointment I will contact you shortly

    thanks for your interesting in making an appointment with me. I will be my pleasure to help you achieve greater wellbeing and peace of mind.

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