Naturotherapy Client Intake Form with Rio de Ki

Section 01

About You

First Name *

Last Name *

Preferred Nickname

Date of Birth *

Preferred Pronouns *

She/her They/them He/him Other

Relationship Status

Select all that apply.

Email *

Phone *

Section 02

Insurance Receipt

Would you like an insurance receipt? *

Verify with your provider that they cover Naturotherapists under the ACNN (Academy of Naturopaths and Naturotherapists of Canada).

Yes No

Street Address

Address Line 2

City

Postal Code

Section 03

Modalities & Focus

Which modalities are you interested in? *

Naturotherapy Bioenergetic Therapy Somatic Therapy Craniosacral / Reflexology Reiki / Energy Work

Which areas would you like to focus on?

Select all that apply.

Pain / Symptom Relief Nutrition & Gut Health NLP & Neural Repatterning Somatic Healing & Emotional Regulation Creating Boundaries Reiki / Energy Work Shadow Work & Subconscious Repatterning Intuition & HSP Tools

Section 04

How You're Feeling

Sleep Patterns

Select all that apply.

Fall asleep easily Wake up feeling rested Difficulty falling asleep Trouble waking up / unrested Wake in the middle of night

Stress Levels *

Pace of Life *

Section 05

Session Package

What package would you like to start with?

Section 06

One Last Thing

How did you hear about Rio? *

Anything else on your mind?

Section 07

Consent & Signature

Signature *

Sign with your mouse or finger

Naturotherapy &
Bioenergetic Therapy
Intake Form

Intake received

About You

Insurance Receipt

Modalities & Focus

How You're Feeling

Session Package

One Last Thing

Consent & Signature

Naturotherapy &Bioenergetic TherapyIntake Form

Intake received

About You

Insurance Receipt

Modalities & Focus

How You're Feeling

Session Package

One Last Thing

Consent & Signature

Naturotherapy &
Bioenergetic Therapy
Intake Form