Information provided on this form is confidential. Please give detailed, complete, and accurate information. Each field must be filled out. For those fields that do not apply, please write in N/A. With gratitude, Jordan Your Name (required) Your Address Your Phone Your Email (required) What are your intentions for our time together? If our work were totally successful, how would things change from where you are now? Do you have any injuries, pains, or aches? How did your injury occur? How long have you had the injury or ailment? What might lie at the root of your health condition? What does your body need in order to heal? Do you have any other injuries or physical problems? What do I really need to know about you that will help me most help you? How willing are you to make substantial changes? When you think about the "big picture of life" what would you say is the most important thing you want? Why do you want this? What has blocked you from having it thus far? Is there anything else I need to know about you? Are you willing to invest resources (time, money, energy) into creating what your truly desire?