New Client Intake

Congratulations on making the decision to commit to your own health and wellbeing. That’s a big step! Now that you’ve scheduled your first session with me, please fill this out at least 24 hours before our meeting. I’m looking forward to helping you on your journey!

Name

First Name

Last Name

Phone

(###)

###

####

Age

Medical Conditions

List any medical conditions you're currently being treated for.

Medications

List any medications you're currently taking and how long you've been on them.

Supplements

List any over the counter supplements you're taking.

Disclaimer

Disclaimer: By typing your full name below, you are stating that you understand Shannon Dahlum is not a licensed dietitian or clinical nutritionist, and any coaching she provides is not intended to replace medical advice.

Payment

Just a reminder: if you haven't already submitted payment, payment will be due at the time of our first meeting. I can accept cash, check, Venmo, PayPal and Zelle.

Got it!