CLIENT INTAKE FORM | Stepping Stones

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CLICK THIS ATTACHMENT LINK TO DOWNLOAD IN-TAKE FORM OR FILL OUT BELOW

NAME AND ADDRESS

TELPHONE NUMBER

EMERGENCY CONTACT

CASE WORKER

DO YOU PLAN ON MOVING OUT?

YES

NO

HAVE YOU RECEIVED ILS BEFORE?

YES

NO

HOW DID YOU HEAR ABOUT US?

ARE YOU ON ANY MEDICATIONS?

YES

NO

IF YOU ANSWERED YES TO LAST QUESTION, PLEASE LIST WHICH MEDICATIONS.

DO YOU EXCERCISE?

YES

NO

PLEASE MARK ANY OF THE FOLLOWING CONITIONS OR ALLERGIES YOU MAY CURRENTLY HAVE

FOOD ALLERGY

ANIMALS

EMOTIONAL CHANGES

INSECTS

MEDICINES

COLD VIRUS

ALCOHOL WITHIN 24 HOURS

KIDNEY ALIGNMENT

TREE/GRASS

SPORTS INJURY

PHLEBITIS

BRUISES

HIGH BLOOD PRESSURE

VARICOSE VEINS

ACUTE PAIN

GRIEF PROCESS

RECENT SURGERY

OPEN WOUNDS

OSTEOPOROSIS

CHRONIC PAINS

BLOOD COT

FEVER WITHIN 24HRS

WEAR CONTACTS

PLEASE LIST IN DETAIL WHAT YOU NEED ASSISTANCE/OR HELP WITH.

Thanks for submitting!

SCHEDULE YOUR SESSION HERE

Bay Area, California

Tel: 510-309-4643

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