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Discovery Scope

Understanding the Whole Person, Not Just the Symptoms

Intake Form Part I

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

Please review our HIPAA Notice of Privacy Practices

Intake Form Part I

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

Please review our

HIPAA Notice of Privacy Practices

To make the process more manageable, the intake is divided into four separate sections, allowing you to complete the assessment one part at a time. Depending on the complexity of your health history and the level of detail you choose to provide, the total completion time for all four sections may range from approximately 15 to 75 minutes.

Before You Begin:  Each section must be completed and submitted in its entirety before proceeding to the next. For privacy and security purposes, your responses are not automatically saved, and partially completed sections cannot be stored, submitted, or resumed at a later time. We therefore encourage you to set aside sufficient uninterrupted time to complete each part before beginning.

Kindly Note: 

To provide the exceptional level of care, precision, and personalized guidance our clinic is known for, we encourage complete transparency throughout your wellness journey. Information that is not disclosed may influence the effectiveness of your customized protocols, recommendations, and overall results. Rest assured, all information shared with us is treated with the utmost discretion and remains strictly confidential.

If you have not already done so, to help us protect your privacy and accurately organize your health records, please create a unique Client Identification Code. This code will be used to identify and link your intake forms, assessments, and clinic records while minimizing the use of personal information within our internal systems. Each individual completing a Discovery Scope must create and use their own unique Client Identification Code to ensure their health records are accurately and securely maintained, even when multiple family members or individuals share the same email address.


Important: Please record your Client Identification Code in a safe place and use the same code each time you complete forms or communicate health information with our clinic, unless instructed otherwise.


Please choose a code that is easy for you to remember but not easily identifiable by others.

Gender
Male
Female
Birthday
Month
Day
Year
Address
Multi-line address
Do you have a Primary Care Practitioner ?
Yes
No
Other
Details of our Holistic Services ..
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