Lolitaire Healey Intake Form- Osteopathy & Wellness Coaching

The AlignedBEing Free Call & Intake Form

*To be filled out if you are interested in The AlignedBEing Sessions* There are 4 steps to this intake form. You need to get to step 4 to book your FREE appointment. The information from this form will help us make the best use of our 30 minutes together.
Please fill out this intake form to the best of your ability. Share as much or as little as you’d like. Some questions may not apply to you, so feel free to leave blank if they are not marked as required.

All documentation and information is confidential.
Step 1 of 4- Personal Information

1 - 2 mins
Name*

First NameLast Name
Email*
example@example.com
Location (country)*
Phone Number*
Please enter a valid phone number.
Birthdate*
How did you hear about us?*

Step 2 of 4- Past History

1 - 5 mins
List your history with any and all physical injuries or accidents (explain in detail if able):
List any professionals you have seen for the above injuries or accidents, including the type of professional and the timeframe:
Is there a history of sexual abuse, assault or harassment? Feel free to expand if comfortable.
Is there a history of physical abuse? Feel free to expand if comfortable.
Is there a history of emotional or verbal abuse? Feel free to expand if comfortable.
Have you ever been diagnosed with a mental or physical health condition? If so, please list:
List any professionals you have seen for any above sexual, physical, emotional or verbal abuse, including the type of professional and the timeframe:

Step 3 of 4- Current Pain and Future Goals

3 - 5 min
1) What are you struggling with the most when it comes to your body, movement or wellbeing? Please provide a brief description.*
2) What is/are your top objective(s) or goal(s) that you’d like to achieve together?*
3) Why is it important for you to achieve these things?*
4) What do you hope to learn from our time together? *
5) Do you have any specific physical or athletic goals?
6) Anything else you’d like to add?

STEP 4 of 4- Book your FREE 30 minute consultation

1 - 2minutes
Book your Free Consultation below. No pressure, just an opportunity to meet and discover if we are a good fit to work together.
Have you booked your FREE 30 minute consultation above?

YesNo
Should be Empty:

The AlignedBEing Free Call & Intake Form