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* 1. Your contact information

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* 2. Are you interested in participating in:

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* 3. Informed Consent
A. Wellness consultations with Brooke are not a medical evaluation. We work with Ayurvedic and Access Consciousness tools to implement lifestyle changes, shifts in your dietary patterns and possibly herbal supplementation. We may also explore therapies such as: yoga, aroma, color and sound therapies as well as Ayurvedic and energetic body treatments. We are excited to assist you in stepping beyond any current physical and mental limitations in your life. 

B. Brooke Pilkington is a Certified Ayurvedic Practitioner, an Access Certified Facilitator and a Birth & Postpartum Doula, not a medical Doctor.

C. If during our consultation, findings suggest a possible medical imbalance, your practitioner will refer you to a medical professional.

D. Ayurveda is the traditional healing system of India, which is based on the idea that each person is unique. Using Ayurvedic and Access Consciousness tools we will design a program that is based on the understanding of your unique body and the unique nature of any imbalances in your life. Our goal is to create health, ease and joy within your body and mind. How does it get any better than that?


Financial Agreement
A. There is a charge of $60 for a 30 minute session with Brooke.
B. There is a charge of $120 for a 60 session with Brooke.
D. There is a charge of $180 for a 90 minute session with Brooke.
E. The payment for all retreats are due 1 week before the date of the event.
H. Any herbs, oils, body work or other products are sold separately from the consultation price.
H. Brooke is open to trade, but arrangements must be made prior to the visit.
I.  Beeing Well does not bill insurance companies for services or herbal products.

Please specify below which financial agreement you are choosing and add your electronic signature.



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* 4. Past Medical History or Family Medical History

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* 5. Food and Supplements

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* 6. Daily Rhythms

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* 7. Digestion

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* 8. Elimination: please mark any that apply

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* 9. Psychology: Please mark any that apply

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* 10. Is there any other information that would be helpful for me to know about your health?

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