Home
About
Our Services
Intake Form
Mental Wellness
Blog
Book An Appointment
Home
About
Our Services
Intake Form
Mental Wellness
Blog
Book An Appointment
Home
About
Our Services
Intake Form
Mental Wellness
Blog
Start Your Wellness Journey
Step 01
Name*
Phone Number*
Consent to Receive Calls?
Yes
No
Email*
Consent to Receive Emails?
Yes
No
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Current Age
Addressed as
Mr.
Mrs.
Dr.
Miss
Him
Her
They
None
Other
Marital Status
Allergies? If yes, list below
What Do You Wish to Achieve From Working With Kiasili Holistic Care?
What Are Your Current Main Wellness Concerns? (Describe the Discomfort Medical / Emotional / Spiritual & How Long Has This Been? What Has Been Taken and Response.
Please briefly tell me your medical history (injuries | accidents | surgeries etc.)
Are You Currently Seeing Any Healthcare Professionals? Any Medications Taken Regularly?
How Are You Sleeping? (How Many Hours, Quality etc.)
Files You’d Like to Share (Medical /recent Blood Work/ Holistic etc.)
Next
Step 02
Please Read the List and Tick Any That You Are Currently Feeling or Have Felt Over the Last 3 Months
Criticized
Overwhelmed
Apprehensive
Uncertainty
Agitated
Paranoid
Intolerant
Muddled
Guilty
Overworked
Aggravated
Paralyzed
Depressed
Rejected
Easily Irritated
Persecuted
Helpless
Anxious
Hopeless
Uneasy
Sad
Grieving
Abused
Fearful
Unable to Grieve
Distress
Impatient
Angry
Worried
Outraged
Sleepless
Nervous
Restless
Intimidated
NONE
Do You Have Any Concerns About the Following Areas – Please Tick and Comment Below
Digestion
Respiratory
Cardiovascular
Urinary
Nervous System
Muscle / Joints
Lymphatic System
Endocrine System
Back
Next
Step 03
Please Give Further Details in Relation to Any Areas Ticked Above or ANYTHING Else You Feel We Should Be Aware of. Please Take a Moment to Consider the Following.
My Family Stress is*
Zero
Minimal
Moderate
High
My Relationship Stress is*
Zero
Minimal
Moderate
High
My Work Stress is*
Zero
Minimal
Moderate
High
My Financial Stress is*
Zero
Minimal
Moderate
High
My Health Stress is*
Zero
Minimal
Moderate
High
Please Take a Moment to Consider How Much Time You Have for Each of the Following.
‘ME’
Zero
Minimal
Moderate
High
Exercise
Zero
Minimal
Moderate
High
Relationship(s)
Zero
Minimal
Moderate
High
Meditation
Zero
Minimal
Moderate
High
Social
Zero
Minimal
Moderate
High
How Did You Hear About Kiasili Holistic Care?
Choose One
Google
Customer Reviews
Other
Submit
Back
