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