Initial Intake Form

Choose the option that works best for you. Complete the form online, or download a printable version to fill out by hand and bring with you.

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Prefer paper?

Download & bring it in

For guests who prefer a printed form, download the guest-friendly version, complete it at your own pace, and bring it with you.

Download Printable Form

Please do not email or upload sensitive medical information through this page. Full Circle provides non-medical wellness services and works alongside licensed medical and counseling professionals.

Complete online

Contact information

First Name *

Last Name *

Phone Number *

Email Address *

Preferred Contact Method *

Your starting point

What are you interested in? *

What are your primary wellness goals? *

What concerns or changes brought you to us?

How long have you noticed these concerns or changes?

Wellness baseline

Please rate how you feel today or over the past week. These ratings give us a starting point for tracking your experience over time. 0 is lowest or most difficult; 10 is highest or most comfortable.

Overall wellness (0–10)

Energy (0–10)

Stress management (0–10)

Sleep quality (0–10)

Physical comfort (0–10)

Ease of movement (0–10)

Bladder/pelvic-floor confidence (0–10 or N/A)

What would meaningful improvement look like for you?

Emergency contact

Emergency Contact Name

Emergency Contact Phone

I understand that FULL CIRCLE Quantum Recovery Studio provides non-medical wellness services, does not diagnose or treat medical conditions, and does not replace licensed medical care or counseling. *

Please do not submit diagnoses, medication lists, trauma details, or other sensitive medical information through this online form. Those topics can be discussed privately through the appropriate process.