Client Intake Form
Reason for visit (prioritized):
Do you use artificial sweeteners?
How much per week of these:
Do you exercise/move/participate in fun sweaty activity?
Do you look forward to it?
Do you feel rested when you wake up for the day?
Do you have pain when you first get up?
Does it go away upon moving?
Would you like to receive our natural health newsletter?
Do you have daily bowel eliminations?
Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?
Are you now, or in the near future, planning to become pregnant?
Is your menstrual cycle regular?
If no, is it longer or shorter than 28 days?
Do you take any supplments?
Do you take any over the counter medications routinely (such as Aleve or Aspirin)?
Do you take prescription medications (prescribed by a licensed medical professional)?
Have you had any surgeries?
Have you been told you have a medical condition by licensed medical professionals?
Symptoms and Areas of Concern (check all that apply)
RELEASE AND CONSENT AGREEMENT
Radiant Tree Wellness, under the umbrella of Radiant Tree Productions, LLC educates in the ministry of Holistic Health and offers information, training, and personal coaching to help you develop a solid root system that nurtures growth and fruitfulness. Those who seek optimum health and wellness from a holistic approach -mind, body and soul- can be confident that every area of concern will be addressed. Our goal is to help you achieve radiant wellness.
Radiant Tree Wellness offers a variety of therapies and techniques that involve improving diet, proper food preparation, reducing stress, eliminating self-destructive habits, and making lifestyle changes to enhance physical fitness, mental alertness, positive attitudes towards life, and personal health awareness. It is important to understand that true and lasting positive results requires compliance, consistency, and commitment.
Radiant Tree Wellness supports and guides you through the process of bringing your body into balance naturally and will be available for e-mail support between appointments. Consultations made by appointment may be recorded. All clients have the responsibility of dealing with any information presented as they see appropriate, and we invite you to consult with your doctor before starting any new modalities or regime. Radiant Tree Wellness does not diagnose or treat, nor do we use the word “cure”.
I understand that I am here to learn about nutrition and better health practices from a holistic and natural perspective and that I will be offered guidance, education, and information about natural and holistic health practices as well as food supplements and herbs as a guide to general good health. I fully understand that those who educate me are not medical doctors, but are natural health practitioners and I understand that the practitioner does not prescribe, diagnose, treat, cure, substitute any medical or psychiatric treatment, nor substitute any medications prescribed by any other physicians or healthcare providers. I understand that those who counsel me should not be viewed as a primary healthcare provider.
I have read the above statements and understand it fully, and accept these statements as true. I request Debbie A. Mirander to perform an evaluation and set up a program for the purposes of enhancing my overall understanding and knowledge in this area. The success of this program is relative to my own efforts, understanding, and capacity to use natural healing principles in my own life.
I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state, or local agencies or on a mission of entrapment or investigation.