top of page

Initial Client Intake Forms

Lex Burgeson, Master Level Splankna Practitioner

Download, complete, sign, date and bring each of these forms to your first appointment:

INTAKE Form: Please print and sign

DISCLOSURE STATEMENT: Please print and sign. If the client is a teen the age of 12 or over, he/she must ALSO read and sign this form.


PAYMENT POLICIES: Please print and sign.


HIPPA ACKNOWLEDGEMENT: Please print and sign


HIPPA DOCUMENT: Please read. Print ONLY if you'd like to keep a copy for your records.

CONSENT TO TREAT MINOR CHILDREN (for children under age 15)

bottom of page