Panimus Integration Intake Form

Your information is kept confidential and helps us support you as you take these courageous steps to support yourself!  If you have any questions or considerations regarding the Intake Form below, contact us here. 

Fields marked with an * are required

After submitting the Intake Form, feel free to set-up an appointment  for a free initial consult or for a full session.

Which offering are you most interested in? Choose only one, we can discuss others when we connect.

Level of Education Completed

Relationship status

What are your Integration Interests?

Please check the box if the statement was TRUE for you before your 18th birthday. Total your checkboxes in the next question.

9 + 4 =