New Client Form

Please submit the following form prior to your initial session.


Name *
Name
Date of Birth *
Date of Birth
Phone
Phone
Address *
Address
Legal Agreement *
I understand that providing incorrect information can be dangerous to my health. I will not rely on Primal Nation and their staff for information as a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment. If I have any concerns or questions about my health, I should always consult with a physician or other health-care professional. Nothing stated or posted on this site or available through any services are intended to be, and must not be taken to be, the practice of medical or counseling care. For purposes of this agreement, the practice of medicine and counseling includes, without limitation, psychiatry, psychology, psychotherapy, or providing health care treatment, instructions, diagnosis, prognosis or advice. By checking the box, I confirm that I understand the above statements and that the questions on this form are true and have been accurately answered.