Session Intake Form

If you prefer to keep some details private until you meet or speak with Dave, feel free to be very brief here or leave some things blank. Another option is to download the intake form here, fill it in, and either email it to or print and send to: Dave Markowitz 2456 NW Northrop St. Ste 1A Portland, OR 97210 at least five days before your session.

Client's Last Name:
Client's First Name:
Preferred email:
D.O.B: (mm/dd/yyyy)
Address:
City / State / Zip / Country:
Preferred phone number you'd like
to be called on, or Skype address:
(We use Skype for calls outside USA, Canada, and Mexico):
Occupation:
Who can we thank for your referral?
(Please be specific.)
Briefly describe any physical / emotional / energetic health challenges or relationship challenges in order of priority:
Briefly describe types of modalities
already tried and their results:
Please give a succinct description of your diet:
Do you...
(yes/no - briefly elaborate):
 
Smoke:
Drink:
Exercise:
Meditate:

Are you currently or have you ever been diagnosed with a mental disorder?
If yes, please explain in detail:

Briefly describe your spiritual beliefs:
Briefly describe
your relationship
status (current/prior):
What is your intention a/o
goal from your upcoming
session(s)?

If you have already scheduled your first appointment, please list the date and time here (include time zone):

What makes you happy?
For phone/Skype sessions: To achieve the best energetic connection, please choose one option below:
Option A:
Provide a URL that features your photo (Facebook page, etc.)
OR
Option B:

Upload a photo (JPEG, GIF, etc. - filesize under 8Mb)

  To be kept in the loop about events and helpful articles for better living, may we sign you up for the monthly newsletter? Your information will never be shared or sold in any way, and you can always opt out at any time.
Newsletter Signup:

I certify that:

  • I have read the disclaimer below;
  • the above information is true, honest, and that nothing pertinent (e.g. mental diagnoses, etc.) has been omitted;
  • that I am 18 years of age or older; (If the information entered above is for a minor, click here to indicate such and that you as legal guardian approve of this and any follow up sessions.)
  • and that I am aware of the full responsibility, 24-hour cancellation policy.
Electronic Signature:
Date: 04/24/2017
(SEND on next page)

Disclaimer:
These concepts are not intended to diagnose, cure, prevent, or treat your symptoms, disease, diagnosis, illness, or alike, or replace your medical treatment in any way, shape, or form. Dave Markowitz, the web-designer/hosting company, book editors/distributors/publishers, Paypal, and so on make no medical claims whatsoever and assume no liability of any kind for the (mis)interpretation or (mis)implementation of this text, written, spoken or implied. Simply use what resonates with you and discard the rest. Remember, it's always best to see (and hug) your Doctor.

Dave Markowitz reserves the right to decline to work with anyone who he deems as an inappropriate match for his services at any time.