We are 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 one of the Holistic Preventive Clinic staff, at a charge of $1.60 per minute.
** IMPORTANT: Please ensure that you have a stable internet connection when completing this form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.)
CONSULTATIONS ARE BY PHONE OR SKYPE ONLY.
At the time of your appointment, call (608) 242-0200
or Skype name Kristina Amelong.
The Holistic Preventive Clinic respects the privacy of its clients. All personal information provided on this form will be held in strict confidence and will not be released to any third party without prior written authorization.