Confidential Client Inake form Question Title * 1. Your contact information Full name? Phone number? Email address? What is your date of birth? How did you hear about Beeing Well? Question Title * 2. Are you interested in participating in: Wellness Consultation with Brooke Energetic Body session with Brooke Ayurvedic Body Treatment with Brooke Seasonal Retreat with Brooke Birth or Postpartum Doula Services Other (please specify) Question Title * 3. Informed ConsentA. 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 AgreementA. 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. Question Title * 4. Past Medical History or Family Medical History Serious Illness Hospitalization Operations Family history of cancer Family history of diabetes Family history of heart disease Family history of mental illness Other (please specify) Question Title * 5. Food and Supplements Any dietary restrictions? Any eating disorders past or present? Any allergic reactions to substances? Please list any medications or supplement you are currently taking along with dosages. Question Title * 6. Daily Rhythms What are your sleep and wake times? Describe your exercise patterns: How often and what time do you eat your meal? Question Title * 7. Digestion Abdomial pain Belching Excessive gas Burning indigestion Vomiting Nausea Heavy after eating low energy after eating Bloaty after eating Other (please specify) Question Title * 8. Elimination: please mark any that apply Constipation Both constipation & diarrhea Food particles in stool Rectal pain or bleeding Diarrhea Bloody stool Unusual color in stool Mucous in stool Other (please specify) Question Title * 9. Psychology: Please mark any that apply Worry Anxiety/fear Overwhelm Spaceyness Insomnia Anger Resentment Jealousy/ Envy Being critical Irritable Lethargy Sadness Depression Head Aches Other (please specify) Question Title * 10. Is there any other information that would be helpful for me to know about your health? Done