New Client Registration Please complete the form below. This enables me to gather the information I need and to ensure our sessions are tailored to you. Name * First Name Last Name Email * Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Languages Spoken / Understood * Educational History * Occupation * Emergency Contact (Name, Phone number, & Relationship) * Do you have any diagnoses impacting your hearing, voice, speech, breathing, or movement? * Please check any that apply: * Allergies Post-Nasal Drip Chronic Cough Chronic Throat Clearing Teeth Grinding Jaw Pain Tongue Tension Reflux None of the Above Do you experience pain or limitations impacting sitting/standing/lying down/moving? If so, please describe below (to the degree that you are comfortable disclosing): Does your professional or personal life involve exposure to smoke, chemicals, or allergens? If so, please describe below (to the degree that you are comfortable disclosing): Does your professional or personal life involve speaking in noisy environments, yelling/cheering, singing, phonation during exercise, talking on a headset, changing your voice, or any other possible vocally straining activities? If so, please describe below: Do you have prior voice and/or physical training? If so, please describe below: What is your expectation regarding our work together (process, outcomes, time frames) * Is there anything else that I should know to ensure our sessions are modified to your needs (eg. dyslexia, possible interruptions to care for family member, etc.). If so, please describe your access needs below: Thank you!