• Client Intake Form
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  • HEALTH:


  • CURRENT RELATIONSHIP:
  • If in a relationship, describe your partner:
  • CHILDREN:
  • PARENTS:
  • Father
  • Childhood Relationship:
  • Mother
  • Childhood Relationship:

  • Any Siblings?

  • Any physical, mental, emotional,or sexual abuse from anyone outside the immediate family?

  • PERSONAL:
  • PRIVACY POLICY Information Collection and Use:Information collection on this intake form is for the sole purpose of providing you with a personalized session with Cindy Skidmore. We do not sell, share, or rent this information with companies or to others in ways different from what is disclosed in this statement without your express permission or unless ordered to do so by a court of law. Sharing:We do not share personally identifiable information about our clients with 3rd parties. We do not rent, sell, or giveaway our email list or customer list to anyone, ever. If you would like not to receive e-mails from us, you can unsubscribe simply by typing that in the subject line of any email we send. Your name will be removed from our e-mail newsletter/event list. DISCLAIMER:A session with Cindy Skidmore is not a substitute for medical or psychological care and is not intended to be for medical diagnosis or treatment. Always seek the advice of your physician or other health care provider with any questions you may have regarding a medical condition. CANCELLATIONS:• As a courtesy, changes or cancellation of your scheduled session needs to be made 24 hours prior to the appointment. • In case of a “No Show” or cancellation without adequate notice, 50% of the session price will be charged. 
  • I have read and understand the Privacy Policy, Disclaimer and Cancellation information.
  • RESEARCH OPTION:You are being given the option to take part in a research study because you are a client of Cindy Skidmore. This research study is being done in an attempt to further develop, enhance, and document results of clients’ experiences. This may also be used as material for a book. If your information is used in the book, all names and personal identifying information will be changed and fictitious information will be used to protect your privacy. There will be no financial compensation for participation in this research option.
  • I would like to take part in the research option described above.
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  • Cindy Skidmore 74075 El Paseo, Suite B2 Palm Desert, CA 92260 website: www.cindyskidmore.com email: cindy@cindyskidmore.com
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