Becoming My Patient

Client Service Agreement

Please read and sign the consent form signature page and return it to me at drleslie@protonmail.com

Client Intake Form - Fillable Version

This version allows you to write directly in the PDF once you download it to your computer, save it and attach it to an email for sending. Please return the form to me at least 48 hours prior to our first appt.

Client Intake Form - Printable Version

This is the PDF version to fill out if you prefer to print it out and fill it by hand. You will then scan and save as a PDF (NOT as a JPG) and send back via email. Please return it to me at least 48 hours prior to our first appt.

The Food Mood Diary - Fillable Version

This version allows you to write directly in the PDF once you download it to your computer, save 3 versions, one for each day and attach it to an email for sending along with your forms.

The Food Mood Diary - Printable Version

This is the PDF version to use if you prefer to print it out and fill it by hand.
Please download and print 3 copies of the food-mood diary and fill it, scan in PDF format (NOT as JPG) and return with your forms.

Hair Sample Collection

Medical Records Release

Becoming My Client

Client Service Agreement

Please read and sign the consent form signature page and return it to me at drleslie@protonmail.com

Client Information Form - Fillable Version

This version allows you to write directly in the PDF once you download it to your computer, save it and attach it to an email for sending. Please return the form to me at least 48 hours prior to our first appt.

Client Information Form - Printable Version

This is the PDF version to fill out if you prefer to print it out and fill it by hand. You will then scan and save as a PDF (NOT as a JPG) and send back via email.
Please return it to me at least 48 hours prior to our first appt.