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Naturotherapy Client Intake Form

Welcome! Fill me in with your holistic background and goals for working together. This will serve for the foundation of our sessions together and will save us time in our initial session.

About You

Your Name(Required)







Preferred pronouns(Required)





MM slash DD slash YYYY

Which best describes your relationship status?(Required)





Do you want an insurance receipt?(Required)


Verify with your provider that they cover Naturotherapists covered with the ACNN (Academy of Naturopaths and Naturotherapists of Canada).
Your Address (If you require an insurance receipt)












Session Preferences

Let me know what you are looking for.
Which Areas Would You Like to Focus On?








What Modalities are You interested in?(Required)





Do you experience any of the following:












Do you experience any of the following:





Please rate your stress levels 1 – 5





Please rate the pace of your life 1 – 5





What's on your mind?

Please let us know what's on your mind. Have a question for us? Ask away.

What package would you like to start with?

Bioenergetic / Naturotherapy





Somatic Therapy





Consent(Required)

By signing this form I consent to a Naturotherapy session using Somatic and Bioenergetic modalities.
I recognize that at times
I release Rio from all responsibility from whatever may come up for me emotionally during or following the session.






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