Intake Form

Thank you for taking the time to complete this form.

First Name

Last Name

Phone

Town/City

Where did you hear about me?

Age

Do you live alone or with someone else?

Do you have children? If yes, how many, and how old are they?

What is your educational background?

What is your current occupation/work situation?

Please list your current health and/or emotional concerns in order of importance. For each concern, please indicate how long it has been an issue and how intense the pain/discomfort is on a 1-10 scale.

Are you currently undergoing other treatment? (E.g. with a doctor, chiropractor or psychologist)

If sessions with me went perfectly, what would be different for you afterward?

Do you experience any digestive discomfort? (e.g bloating, constipation, diarrhoea or pain)

Do you have any allergies or sensitivities? To what and what reaction do you experience?

How many hours of sleep do you get on average?

Do you exercise or move your body in other ways? What kind and how often?

What is your current stress level and what are your main stressors?

How would you best describe your general energy level during a typical day?

Very low

Low

Fairly normal

High

Please list any prescription or OTC medications or supplements you're currently taking:

Please list surgeries and/or hospitalisations including reason and year:

Please list any previous chronic or long-term illnesses, ailments or pain:

Please list any accidents or injuries? (e.g., concussions, falls, fractures, car accidents)

Are there any stressful events or periods in your life that continue to affect you regularly? Please describe each briefly, using a few words and the year(s) (e.g., 'Divorce, 2020', 'Burnout, 2008-10')

What helps you feel safe and calm when you feel overwhelmed or stressed?

What brings you joy and gives you energy?

Is there anything else you think I should know or any special considerations I should be aware of?

Consent and Agreement

Britt Toksvig Jørgensen is a holistic mind-body practitioner. Her sessions are designed to support the body's natural capacity for healing and balance. Britt draws upon a range of modalities, philosophies and methods, primarily Brain Network Attunement and BodyIntuitive. Read more at www.britt.dk.

I acknowledge that the sessions do not replace medical advice, diagnosis or treatment.
I understand that Britt does not diagnose diseases, disorders or conditions, nor does she prescribe medication or dietary supplements.
I acknowledge that Britt is not an authorised healthcare professional, licensed physician, psychologist, dietitian, or naturopathic doctor, and that she does not hold a medical degree.
I understand that, in rare cases, I may experience temporary fatigue or low energy following a session, particularly if I have been under intense stress. I am encouraged to contact Britt if I have any concerns or experience unusual reactions after a session.
I acknowledge that I am personally responsible for decisions regarding my health and well-being and for how I choose to use any information provided during a session.

Consent to the Processing of Personal Data

I consent to Britt Toksvig Jørgensen processing my personal data, including health information, that I voluntarily provide in connection with my sessions. My information will be handled confidentially and securely in accordance with applicable data protection legislation and will not be disclosed to third parties unless I have given my consent or disclosure is permitted or required by law.

I have been informed that I may withdraw my consent at any time and request the deletion of my information, to the extent permitted by law.

Yes, I have read, understood and agree with the above.