All About Wellness

Holistic Approach to Well-Being

Client Intake Form

Date

I am happy to help you with any part of your healing program! By submitting this intake form, you are setting your intention to have a phone consultation with me, Yani Kelly

The All About Wellness respects the privacy of its clients. All personal information provided on this intake form will be held in strict confidence and will not be released to any third party without your prior written authorization.

Name

Phone Number

Street

Zip Code

Height

Date of Birth

Blood Type

How many times per day do your bowels move?

Email Address

City

Occupation

Blood Pressure

State

Weight

Cholesterol Levels