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New Patient Application Form

We have become adept at knowing who we can help. Once your application is submitted, you will be REQUIRED to book an appointment time to discuss your application with us.

If you're interested in working with Keesha 1:1 and we decide after our meeting this is a good fit for us both, we will proceed with our new patent intake process and send you our new patient intake form, practice policies, waivers, payment information, and instructions on how to book appointments.

If you're interested in Immersion Retreats or want to learn more about our 6 month Academy for Integrative Health Coaching, we will discuss your needs when we meet as well and proceed from there!

Please fill out the form below in as much detail as possible so that we can review your application and your requests fully before meeting with you:

First Name *

Middle Name

Last Name *

Date of birth *

Gender *

Contact Information

Email *

Phone

Home Phone

Business Phone

Billing Street Address 1 *

Billing Street Address 2

Billing City *

Billing State *

Billing Postal Code *

What health challenge are you wanting solved? *

What have you already tried? *

What do you think you need to heal? *

Do you have an autoimmune disease? If so, which one(s)? *

Do you have a history of childhood or adult trauma? *

Have you tried therapy to treat your illness or disease?

What is The Primary Way You Want To Work With Dr. Keesha?

Work with Dr. Keesha 1:1

Attend in-person deep immersion retreats

Become a certified health coach through our 6-month Academy For Integrative Medicine (AIM) program

By providing your phone number, you agree to receive text messages from Dr. Keesha for marketing purposes and program updates . Message and data rates may apply. Message frequency varies. You can reply STOP to unsubscribe at any time. By checking the box, you also agree to our Terms and Conditions and Privacy Policy.

Read our privacy policy here and Read our Terms and Conditions Here

NOTE: As an Integrative Medicine Medical Provider Dr. Keesha has specialized her clinical focus in digestive and hormonal health and in reversing autoimmune disease. She does not take insurance and will not act as your primary care provider. Dr. Keesha will be acting as your health coach when conducting virtual/telephone consultations and online teaching programs.

LEGAL NOTICE:

Information on this web site is provided for informational purposes only. This information is not intended as a substitute for the advice provided by your physician or other healthcare professional. Do not use the information on this web site for diagnosing or treating a health problem or disease. Always speak with your physician or other healthcare professional before taking any medication or nutritional, herbal or homeopathic supplement, or using any treatment for a health problem. If you have or suspect that you have a medical problem, contact your health care provider promptly. Do not disregard professional medical advice or delay in seeking professional advice because of something you have read on this web site. Information provided on this web site DOES NOT create a doctor-patient relationship between you and any doctor affiliated with our web site. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

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