New OI Client Registration Please complete the form below. This enables me to ensure our sessions are tailored to you. Name * First Name Last Name My pronouns * Age * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Religion Languages Spoken / Understood * Sexual Orientation Educational History * Occupation * Emergency Contact (Name, Phone number, & Relationship) * Do you have any diagnoses impacting your hearing, voice, speech, breathing, or movement? * What other therapeutic/mental wellness professionals work with you? * Have you faced/do you face any serious health concerns? * Please Check Any That Apply: * Drink Alcohol Use Non-Prescription Drugs Smoke Cigarettes Drink Caffeinated Beverages Use Prescription Drugs None 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!