Let's start by
getting to know you.

This intake form helps us understand your goals, your health context, and whether our programs are the right fit for you. Your answers will be reviewed personally and thoughtfully by our clinical team.

Which program do you wish to sign up for?

Personal information

What do you plan to achieve with us?

Eligibility Acknowledgements and Permissions

Before continuing, please review and acknowledge the statements below. These help ensure clarity around how your information is used and what to expect from the screening process.

Accuracy & Record Use

I confirm the information I provide is accurate and understand it is used to evaluate eligibility and may become part of my medical record if a patient relationship is established.

Scope of Screening & Medical Responsibility

I understand this screening is not a diagnosis, does not create a provider-patient relationship, does not replace primary, specialty, or emergency medical care, and that I should seek emergency services or contact my primary care provider for urgent symptoms.

Review, Contact & Financial Disclosure

I understand my responses will be reviewed before any consultation is scheduled, consent to being contacted regarding eligibility and next steps, and acknowledge that Profeta services operate on a self-pay basis. Certain diagnostic testing may be performed by trusted external laboratories and billed directly by the lab; depending on my insurance plan, these costs may be partially or fully covered.

The information you share with us is used only to evaluate eligibility, support your care journey, and communicate next steps, and is handled with strict confidentiality and appropriate security measures.

Let's start by getting to know you.

Let's start by
getting to know you.