Space for Life

Street Address

City, State, Zip

Phone Number

Your Custom Text Here

Space for Life

History for New IST Clients

If you could take a few minutes to fill out this form before our first appointment that would be wonderful. We will review it as well as go over some other questions at our first session. Go into as much or as little detail as you like. Make sure you have also completed the New Client Personal Details form located HERE.

Thanks!
Cecilia
ox

Name

First Name

Last Name

History: significant accidents, illnesses, surgery (particularly abdominal), hospitalisation, pregnancies, life events etc...

Psychiatric history, Psychiatric Drugs taken, other therapies

Do you smoke cigarettes

Yes

Do you drink alcohol?

Yes

Do you do drugs (incl cannabis)?

Yes

If you answered yes to cigarettes, alcohol or drugs, please indicate below the frequency of use and the period of use in years and months.

Please list all other prescription medication and/or supplements currently taken

Please outline your reason for requesting sessions

Please provide a history of any other forms of spiritual work you've been involved with (please indicate past or present)

Is there anything else you'd like me to know?