Forms

Please fill out the Medical History, Reliable Symptoms and Contract forms before your first visit.

If you also struggle with ADD/ADHD/OCD or Anxiety, please also fill out PD1 and PD2 forms.

You can fill out each of these forms online and then send them to my email or bring them to your appointment.

How to fill out online forms:

1. Click the desired form below and download to your computer. 

2. Upload required forms below and fill out forms online.

3. Download filled out forms and email to hpjane@gmail.com

FORMS:

• Medical History - Click Here.
• Reliable Symptoms - Click Here. Use the reliable symptom chart to think about how your symptoms or YOU as a whole feel with your most bothersome problem. I need only the OBVIOUS and STRONG symptoms to be meaningful. Test these modalities out before our appointment if you get a chance. If you don’t understand them all, it's ok. We will go over the list at the appointment.
• PD (Perception Disorder) 1 - Click Here.
• PD (Perception Disorder) 2 - Click Here.
• Contract – Click Here. This form describes the patient/client relationship and agreement. If fees vary, the changes will be agreed upon in office and documented.
• Remedy Instructions - Click Here.
• What To Expect - Click Here.
• Follow-Up Intake - Click Here.