Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Primary Phone *Alternate PhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBirthdate *Emergency contact FirstLastEmergency contact phoneHow did you find me?Are you currently seeing a medical practitioner or therapist? *YesNoList the type of medical practitioner and/or therapist(s) you are currently seeing Example: Chiropractor, Acupuncturist, OsteopathAre you currently taking any medications or supplements? *YesNoList any medications and/or supplements that you’re taking.Past medical history. Please list all past injuries surgeries illnesses or accidents.Why are you coming to see a holistic life coach/ energy therapist? *What are your current goals for our work together? *Emotional state. Please check all of the following feelings you have experienced in the past few months *AbuseAgitatedAggravatedAngryAnnoyedAnxiousApathyApprehensiveBeautifulCriticizedDepressedDespairDistressedEasily distractedEasily irritatedGrievingGuiltyHelplessHopelessImpatientIntimidatedIntolerantMuddledNervousOutragedOverwhelmedOverworkedPanickedParalyzedParanoidPersecutedRejectedResentfulRestlessSadTerrifiedUnable to grieveUncertainWorriedPlease rate your level of family stress. *NoneMinimalModerateSeverePlease rate your level of work stress. *NoneMinimalModerateSeverePlease rate your level of financial stress. *NoneMinimalModerateSeverePlease rate your level of health stress. *NoneMinimalModerateSevereApproximately how much time do you spend each week to relax? *None1-2 hours3-5 hours5+ hoursPlease list any activities you do to relax.How many hours a night do you sleep? *Is your sleep restful? *YesNoIf you have physical discomfort, please share where your aches and pains are. List area and indicate the severity of the pain with 1 being slight and 10 being very severe.Agreement to Terms of Service *I have read and agree to the following Terms of Service. *It is my choice to receive holistic life coaching/energy therapy sessions with Donna Burick. I understand that this is not a substitute for medical treatment or medications. I am aware that Donna does not diagnose illness or disease nor did she prescribe medicine. I understand that my participation in these sessions is voluntary and that at any time I may choose to end my participation. I acknowledge my responsibility for exercising my judgment and initiative and choosing to receive these sessions. I also acknowledge that all information given to Donna Burick is 100% confidential. Sessions must be canceled 24-hours in advance to avoid paying for your scheduled session. By this consent, I knowingly and voluntarily assume responsibility for my healing process.Please Note: 24-hour cancellation notice required. Sessions must be canceled 24-hours in advance to avoid paying for your scheduled session.Please ensure you see the message "Thanks for completing this form" After you hit the submit form. If you do not see the message you have missed some information in the form above. Look for the "This field is required" message for where information is required. Please review the form and enter the missing information and then press the "submit" button again.Submit
